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MONITORING WELL INSTALLATION REPORT <br /> Date: 1 J ° I a GI b CONSTRUCTION <br /> Premise Address:_(ID M t+h� an S T ' Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> �^. Bentonite (from) (to) <br /> Inspector: ��" v ` Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion- Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> i <br /> Driller: casing <br /> height <br /> Consultant f-r(� <br /> Geologist <br /> ABOVE-GROUND —WT <br /> COMPLETION CHRIM-BOX <br /> SPECIAL PERMIT INFO. Ground SuAaca COMPLEnON <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) tt <br /> If yes, location and distance - tt <br /> tt. <br /> — m <br /> = n <br /> SAMPLING = <br /> abtted � <br /> Holding Temperature <br /> vavW Method (30ff&s = P <br /> ack_ <br /> Screening Method Lf <br /> Tracking Sheet - /n) — <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUPING Bags cement <br /> i Buckets bentonite <br /> Depth to water_ZZ Ll— Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/n) <br /> Quantity Installed Discussed with geologist: - (y/n) <br /> Type of method <br /> EH 29 29 <br /> N <br />