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141ITORING WELL INSTALLATION REPOR - a <br /> Date: -Z 3 CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) 7rD (to) 5a <br /> Well No.: Filter Pack (from) AM (to) <br /> Bentonite (from) 4 (to) <br /> Inspector: Grout (from) (to) O <br /> Drilling rig type C� <br /> Permit No. Z'3 (p Auger O.D. I.D. <br /> Completion - Stove pip stie (circle one) <br /> Drilling Company: ..II C <br /> Drillercasing <br /> y height <br /> Consultant <br /> Geologist <br /> ASCVE.GRCUND CHR TY-BOX ' <br /> CO[FLETiON COMPLEMN <br /> SPECIAL PERMIT INFO. Ground S40ace <br /> Distance to sewer line gf0ut <br /> Domestic well on site - (y ICU)) <br /> If yes, location and distance - �- <br /> g^ b <br /> SAMPLING s <br /> Holding Temperature " <br /> — <br /> qrzVW Pack <br /> Method <br /> Screening Method WKw =_ <br /> Tracking Sheet • (y/ n) 79 _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT T <br /> Contamination Noted - ( )1 n <br /> Storage Location_ M Atly Casing type <br /> Blank_ TD ft. Screen Zo ft. <br /> SIot size .02 <br /> GROUTING - Bags cement i2 <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios o Filter Pack type/size <br /> Installation Method Surge Block: n ) <br /> Quantity Installed Discussed with.geologist: - ( n <br /> Type of method <br /> EH 29 29 i <br />