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MONITORING WELL INSTALLATION REPORT <br /> �D CONSTRUCTION <br /> Date: � _ <br /> l Total Depth D � <br /> Premise Address: ' Screen Length (from) (to)i <br /> — / Filter Pack (from) 7 (to)`-S <br /> Well No.: Bentonite (from) 5•S (to) ?. r <br /> ll,Y,, t��� Grout (fro ) -3 (to) ,ta, <br /> Inspector. Drilling rig e <br /> Auger O.D. u I.D. :, <br /> — �,Qstr <br /> Permit No. ��s��-� ®e 3�3 � — Completion - Stove pipe/chrisde box (circle one) <br /> L <br /> Drilling Company:_ `V <br /> Ititi� casing <br /> Driller: <br /> height <br /> Consultant <br /> Geologist U ` /tgpyE-GRCUND CriRPT_Y-3OX r <br /> COWFLEt TCN COWPLEMCN <br /> C�rwrd Su•tacs <br /> SPECIAL PERMIT INFO. <br /> So t gru.K <br /> Distance to sewer line <br /> 3. ft. <br /> Domestic well on site - (y/ n ) 7 ft. <br /> If yes, location and distance - <br /> SAMPLING <br /> :a�cn — <br /> d .� �(lY4l FclC?C <br /> Holding Temperature =_ <br /> Method = <br /> Screening Method : <br /> Tracking Sheet - (y/ n ) = n, <br /> SPOILS <br /> MATERI A /DEVELOPNiENT <br /> Storage Method <br /> Contamination Noted - (y Casing type <br /> Storage Location glank 7 fr. Screen�G__ ft' <br /> Slot size <br /> Bags cement z _ <br /> GROUTING Buckets bentonite 2 <br /> S Bags sand/gravel l b 6 <br /> Depth to water _ f Filter Pack type/size 2 <br /> e" <br /> Mix Ratios /h s ` Surge Block: - �/ 11 ) <br /> Installation Method <br /> y�5� � Discussed with geologist: - (/�)/ n ) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />