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&MONITORING WELL INSTAL ATION REPO..:' <br /> Date: CONSTRUCTION <br /> Premise Address:,-•,_ Total Depth (C- <br /> Screen Length (from) i (to) A <br /> WeII No, - _ Filter Pack (from) 4V (to) n•o <br /> Bentonite (from) t a (to) r <br /> Inspector. 1�4w t:� Grout (from) (to) <br /> Drilling rig typq_0 <br /> Permit No, Auger O.D. <br /> Completion - Stove pip c ir�boxcircleone) <br /> Drilling Company: 5 P\\���-u.yr� <br /> Driller• ,. 'b !��V casing <br /> . height <br /> Consultant ✓ <br /> Geologist (� lW1 -- <br /> ABOVE-GROUND CiiF4tM430X <br /> 00MPL£T10N COMPLETION <br /> SPECIAL PERMIT INFO. Gfcurid Surface <br /> Distance to sewer line �]! - pram <br /> + Domestic well on site - {y/ n) <br /> If yes, location and distance - to S <br /> i v•�ft. ft. <br /> A � <br /> SAMPLING slar.&d — <br /> t <br /> Holding Temperature "1 <br /> Method <br /> Screening Method l <br /> Wracking Sheet - n } <br /> ft. "w is <br /> SPOILS <br /> Storage Method kvu MATERIALS/DEVELOPMENT <br /> Contamination Noted - {y si ) <br /> Storage Location 4 Casing type -E <br /> Blank 10-aft. Screen_ ft. <br /> Slot size <br /> GROUTING . Bags cement <br /> Bucks ntonite u, <br /> Depth to water All Bags san vel <br /> Mix Ratios < Filter ack type/size . <br /> Installation Method Surge Block: - ( y/ i <br /> Quantity Installed ti 1, Discussed with <br /> Type of method ( �f <br /> EH 29 29 i <br />