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MONITORING WELL.INSTALLATION REP RT <br /> Date: �/�1 I �1 CONSTRUCTION <br /> Premise Address: (� �7� ( 'tc t- Pa Total Depth�� <br /> /t1 W 2 Screen Length (from) 10 D (to) 0 <br /> Well No.: Filter Pack (from) 0 0 to 7 <br /> Bentonite (from) (to) <br /> Inspector. K Grout (from) 7 )(to �1�2 <br /> Drilling rig type rerl E / <br /> Permit No. Auger O.D. I.D. <br /> completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> 7m=[ heigh <br /> Consultant C <br /> Geologist -- - 4 <br /> ABCVE•GACUND CF9aISTY•s30X <br /> CCMPLE'TION CCMPLEnCN <br /> SPECIAL PERMIT INFO. p=rd Sulwo i <br /> Distance to sewer line orae <br /> DR <br /> Domestic well on site - ( y/ n ) 713 <br /> ff. <br /> If yes, location and distance - ft \ <br /> — m � <br /> c <br /> SAMPLING doral <br /> soricn — <br /> Holding Temperature = vd <br /> Method — G <br /> `6 <br /> Screening Method <br /> Tracking Shcet - ( y/ n ) _ --fj <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 o , 0 I b <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel 2-11T <br /> Mix Ratios Filter Pack type/size_ T/2 <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: • ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />