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MONITORING WELL INSTALLATION REPORT ' <br /> Date: �� D� CONSTRUCTION <br /> Premise Address:LL&e- Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove ipe/cltristie box (circle one) <br /> Drilling Company: L"L4 <br /> Driller: T casing NlA <br /> T height <br /> Consultant{ <br /> Geologist ►' �+�1 I G/�� I t�J G�2 -a S N <br /> ABOVE-GROUND C19itm-aox <br /> COWLETION CCMPLEnCN <br /> SPECIAL PERMIT INFO. Grourd Surtact <br /> Distance to sewer line U �k- grout <br /> Domestic well on site - y/ n ) , ✓ d" I ° �_.ft, <br /> If yes, location and distance - g, <br /> tt. <br /> SAMPLING Nl-,q sloned <br /> socicn <br /> Holding Temperature GMVW Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> ft. <br /> SPOILS /Gk <br /> Storage Method MATERIALS/DEVEI.OPMENT NIA <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Z �� S Bags sand/gravel <br /> Mix Ratios "#, t Filter Pack type/size <br /> Installation Method ,&l &Lt, Surge Block: - (y/ n ) <br /> Quantity Installed I Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />