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MONITORING WELL INSTALLATION REPORT <br /> Date:—,LS///3Irz- <br /> CONSTRUCTION <br /> Premise Address: ��n �• ,(�p-(�` (� <br /> Total Depth 25 <br /> Well No.: FIz 00/ Screen Length (from) (to) <br /> Filter Pack (from) <br /> Inspector. o-C Bentonite (from)(CO)— <br /> Grout —�(Co) <br /> (from) � <br /> Permit No._5 20U �c (o (P Drilling rig type (to) <br /> Auger O.D --------------- <br /> I. . <br /> Drilling Company � 0 Completion - Stove pipe/cluistie box (circle one) <br /> Driller: <br /> casing <br /> Consultant_ IV S • 7— height <br /> Geologist_ ` T <br /> ABCVE-GAC(JND ` T <br /> Ct4itSTY30X <br /> SPECIAL PERMIT INFO. CONFL_ETICN CCt,1PLETICN <br /> Grourxf Svfacs <br /> Distance to sewer line <br /> Domestic well on site - FY—/n�) grout <br /> If yes, location and distance - _ It <br /> tt. tt. <br /> SAMPLING <br /> tlonad = c <br /> Holding Temperature ti/A a'"°n = <br /> Method Fac* <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method ti/A MATERIALS/DEVELOPMENT <br /> Conramination Noted - (y/n <br /> Storage Location Casing type 3/y �Me <br /> Blank fr. Screen <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Z6 'a0 Bags sand/gravel <br /> Mix Ratios_ c afi Cp Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> EH 29 29 Type of method <br />