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MONITORING WELT.INSTALLATION REPORT <br /> .Date: h5l' . ., fi a ... CONSTRUCTIONA. <br /> { .Premise Address: ) . llt& _ Total Depth <br /> Screen Length (from) (to) <br /> .Well No. C/ I/t 4 Filter`Pack (from} (te) <br /> Bentonite (from) (to) <br /> Inspector. Grout,, _..(from) (to) <br /> � <br /> ; 4 '' _ar Drilling rig type <br /> -Permit No...r . «` r: . .,;; Auger O.D.� I.D. 4� «. <br /> i Completion - Stove pipe/christie box (circle one) a <br /> ..Drilling Company: <br /> t: <br /> Driller -... _ �; casing , <br /> •Consultant <br /> Geologist <br /> A.BQVE-GAG�iJh1D SCFi7.,�TY-SOX <br /> C.OMPt ET�CN <br /> �-- <br /> SPECIAL PERMIT INFO. �}} Ground Surface ^ FpF <br /> �, -.rc - ..� nit «,r w. .a-.,.....- ,y. � _ .e- - ( 4 • ti- _. � _ �, � � cel L <br /> t.„ grout <br /> I Distance to sewer line <br /> Domestic well cin site (y/n )- <br /> If <br /> )-If yes, location and distance a Y � { �I _ Dt. ; <br /> SAMPLING _ <br /> ,lct'.o.� <br /> " Y — o �• - <br /> Holding Temperature <br /> Methodi <br /> Screening Method. <br /> : Tracking Sheet (y/n ) -Y <br /> IF <br /> f SPOILS ' <br /> t .Storage.Method . _ MATERIALS EWLOPMENT <br /> E Contamination Noted - (y/ n ) i <br /> ' Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> f GROUTING Bags cement l <br /> L7—_ _ .. ,h, ,�..._ _ Buckets bentonite . <br /> Depth to water Bags sand/gravel <br /> ' .Mix Ratios . Filter.Pack type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> -Quantity Installed, - — -Discussed with geologist. -.(y/ n } . <br /> Type of method <br /> 1H29-29,­ <br /> . .. .. - r . <br />