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MONITORING WELL INSTALLATION REPORT <br /> Date:_ 1-1-16 I(0 CONSTRUCTION <br /> Premise Address: �o 1S VO ar Gf 7t Total Depth <br /> Well No.: Screen Length (from)_ C) (to) <br /> Filter Pack (from) (to)_ _ <br /> Inspector: �u��A Bentonite (from) (to),-6z_ <br /> Grout (from)_- ,PJ (to), _ <br /> Permit No. Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Company: ��� ` Completion - Stove pipe/christie box (circle one) <br /> Driller:—___S�{ <br /> casing <br /> Consultant height <br /> Geologist_ T <br /> Q ASOVE-GROUND <br /> COWLETION CHRWY4= <br /> SPECIAL PERMIT INFO, - COMPLEMON <br /> - <br /> ���Ground Surface 7�--. <br /> Distance to sewer line Grout <br /> Domestic well on site - n ) <br /> If yes, location and ance - �b s. n <br /> = m <br /> — o <br /> SAMPLING c <br /> 0 <br /> Matted — c <br /> Holding Temperature_ , sec4on = B <br /> Method_ L " (n 0 rw <t, -" = pnV1W Pack <br /> Screening Method_p <br /> Tracking Sheet - / nCY <br /> ) s: <br /> SPOILS n. <br /> Storage Method__!��AAAA MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( /'n ) <br /> Storage Location mn S 1--k-( Casing type '' 3r�N g rJ <br /> Blank fY. Screen $ h, <br /> GROUTING Slot size__ n� <br /> Bags cement <br /> Depth to water_ .wi �, ' Buckets bentonite <br /> Mix Ratios Bags sand/gravel <br /> Installation Method Filter Pack type/siz- <br /> Quantity Installed U Surge Block: - (y/ n ) <br /> Discussed with geologist: - (y/n ) <br /> EH 29 29 Type of method <br />