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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth 2-3 ) <br /> Screen Length (from) <br /> Well No.: im W —b Filter Pack (from)— t 1 r (to) 7 3 <br /> Bentonite (from) �T (to) <br /> Inspector. _ tL�66nn_CZ­1_ . Grout (from) (to) <br /> Drilling rig type <br /> Permit No._ S SZOh e.S S� Auger O.D. I.D. <br /> Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling Company: �/�D�rN�I c� � <br /> Driller: casing <br /> height <br /> Consultant d— '4 <br /> Gt I fits <br /> GeologistMA( <br /> A3CVE-GiqC4JN0 <br /> COMPL.r�TlON CI•Ws.ST'Y-30X <br /> coti+P�mcN <br /> SPECIAL PERMIT INFO. Ground Sutacy <br /> Distance to sewer line grout <br /> Domestic well on site,,- (y n ) <br /> If yes, location and distance - ft._L2 <br /> M• C. <br /> 0 <br /> SAMPLING tlorai = c <br /> tocicn —' <br /> Holding Temperature <br /> Method - — ¢'Yd Pack <br /> Screenin; thod .r — <br /> Trackin Shcet - (y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamin . n Noted - (y/ n ) /y <br /> Stor ocation Casing type <br /> Blank 3 ft. Screen Its ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water_ -J 1 (z Bags sand/gravel <br /> Mix Ratios —� Filter Pack type/size <br /> Installation Method Surge Block: - (y/0) <br /> Quantity Installed Discussed with geologist: - ( y,�n ) <br /> Type of method <br /> EH 29 29 <br />