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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth ' <br /> Screen Length (from) <br /> Well No.: ) �-_ Inti u I—(n Filter Pack (from) <br /> Bentonite' (from) <br /> Inspector; Grout (from) <br /> Drilling rig type <br /> Permit No. S3 y Z Auger O.D. I,D. <br /> Drilling Company: hA I Completion -Stove pipe/christie box (circle one) <br /> � <br /> Driller: 4�C A rt I Ami— i- cas ing <br /> height <br /> Consultant C <br /> Geologist c'tC' <br /> ABOVE-GAOUNQ <br /> Yzm%, 'YVt CONJPLETION CHR*T f-80X <br /> SPECIAL PERMIT INFO, Ground SurfaceCOMPLETION <br /> Distance to sewer line prow <br /> Domestic well on site - n <br /> If yes, location and tance - ft. <br /> A <br /> SAMPLING ' <br /> slatted Y.l C <br /> toclon <br /> Holding Temperature on,_t CA <br /> Method 72velpack <br /> Screening Method cam- 3 . <br /> Tracking Sheet - i/ n ) <br /> ft. .tt —ft. <br /> SPOILS <br /> Storage Method S MATERTALS/DEVELOPMENT <br /> Contamination Noted - (y/©) <br /> Storage Location _Qr Casing type 7— <br /> Blank <br /> Blank ' ft. Screen Z_o ft. <br /> Slot size <br /> GROUTING Bags cement <br /> r <br /> Depth to water ^� Buckets bentonite <br /> _ O Bags sand/gravel S <br /> Mix Ratios Filter Pack type/size <br /> Instailation Method Surge Block: - �y/- n ) <br /> 0 <br /> Quantity Installed Discussed with geologist: . ( y/001 <br /> EH 29 29 Type of method <br />