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MONITORING WELL INSTALLATION REPORT <br /> Date: 0 � CONSTRUCTION <br /> Premise Address: W t t Cd* 0-f �T/_� ��- Total Depth Sb <br /> 17_'- Screen Length (from) Sb (to) <br /> Well No.: Qty -G Filter Pack (from) 5-6 (to) <br /> p Bentonite (from) 13 (to) <br /> k <br /> Inspector: 'i�n�C'"� Grout Ur (to) �.�i..�P <br /> Drilling rig type 1 U <br /> Permit No. Auger O.D. I N 6 I.D. S( s <br /> • Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: /LCL ev <br /> Driller: casing <br /> height <br /> Consultant f5y�C— <br /> I <br /> Geologist C- T <br /> A80VE-GR0UND <br /> Ca MPLEf CN COMPl.ET10N CMPLEMN <br /> SPECIAL PERMIT INFO. Ground Surlacs <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n ) <br /> If yes, location and distance - ---sss---------- <br /> ft. <br /> = m <br /> a <br /> = o <br /> — c <br /> SAMPLING <br /> slotted � <br /> aacdon — � <br /> Holding Temperature <br /> Method ' _ VIVW P <br /> ack <br /> Screening Method C _ <br /> Tracking Sheet - (y/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 0.01t) <br /> GROUTING Bags cement <br /> Buckets bentonite _ <br /> Depth to waterk 1b Bags sand/gravel 3 <br /> Mix Ratios do oa.k Filter Pack type/size 3 <br /> Installation Method Surge Block: - (y/ ) <br /> Quantity Installed Discussed with geo ogist: - C/ n) <br /> Type of method <br /> EH 29 29 <br />