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MONITORING WELL INSTAL.IATION REPORT <br /> Date: 7/�1�L � 1 CONSTRUCTION <br /> Premise Address: /ZS' `� Total Depth <br /> Screen Length (from) (to) <br /> �1� 9/� - Filter Pack (from) (to) <br /> Well No.: <br /> Bentonite (From) (to) <br /> Grout (from) (to) <br /> Inspector. Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> c$sinq <br /> Driller: / height <br /> Consultan <br /> Geologist �,gpyE��CUND <br /> CO F.SP Lr�'Tf0 N Ct-Ai5'TY-30X <br /> COMPLEMON <br /> MI ='nd Sufacs <br /> SPECIAL PERT INFO. C3 <br /> prOut <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - h• <br /> tt. <br /> m <br /> ••N C <br /> O <br /> SAMPLING •(orA,i = <br /> _ gnV1W <br /> Holding Temperature <br /> Method <br /> Screenin;Method <br /> Tracking Sheet - (y/ n ) — <br /> • tt• <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) ` <br /> Storage Location Casing type <br /> Blank ft. Screen h• <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water 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 />