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MONITORING WELL INSTALLATION REPORT <br /> Date: �1� � CONSTRUCTION <br /> Premise Address: Total Depth /C <br /> Screen Length (from) /60 (to) l <br /> Well No.: Filter Pack (from) (to) 7-1 <br /> Benronite (from) '73 (to) 'T <br /> Inspector. !/s:� S Grout (from) ;ZZ (to) �:Iu . F-. <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> r Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist <br /> �f ABOVE-GRCUND <br /> CO4l �lON STGCTN <br /> SPECIAL PERMiJ X <br /> 7PRPM Ground Su(an <br /> Distance to sewer line c�*'� --' zs- 7 grout <br /> Domestic well on site - ( y/ n ) G r <br /> If yes, location and distance - <br /> = e <br /> r <br /> e <br /> C <br /> SAMPLING abnai <br /> ©C aor'cn <br /> Pack <br /> Holding Tem�p"e"r�a"te <br /> Method wyte tic 'i _ gnvw <br /> Screenin;Method <br /> Tracking Shcet - ( y/ n ) <br /> tL <br /> SPOILS <br /> Storage Method cif f' iy MATERIALS/DEVELOPMENT <br /> Contamination Note - y n ) <br /> Storage Location / e-svq Casing type c�ul'-Q/"J 4 <br /> Blank ZT— ft. Screen ft. <br /> Slot size r n <br /> GROUTING Bags cement <br /> r Buckets bentonite P . Czrs .� <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method T.rrrriwa:i Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />