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MONITORING WELL INSTALLATION REPORT <br /> Date: IL;�0 CONSTRUCTION <br /> Premise Address: �n -� " Total Depth 1 f <br /> Screen Length (from) ( 1 (to)_111; <br /> Well No.: I�v� °� �' Filter Pack (from) 1%4S (to) ►12 <br /> Bentonite (from)_ if 3, (to) u o <br /> Inspector*. L Grout, (from) t(o <br /> Drilling rig type_ <br /> Permit No. ___--Auger O.D. ��t�� I.D. bl '`1 <br /> - "Completion .Stove,pipa/christie box (circle one) <br /> Drilling Company-.- <br /> Driller'. <br /> ompany:Drillercasing <br /> ! F he_ght. <br /> nIV <br /> s <br /> Consultant ( � �'-�-y � <br /> ktb Y t / <br /> Geologist <br /> A_o <br /> OvE-G R CCJN D <br /> !i C}-A:STY-3JX <br /> CCtY ==i ICN <br /> SPECIAL PERMIT INFO. Gr=rd Su-facs <br /> Distance to sewer line Drat <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - <br /> yrs n. <br /> M <br /> SAMPLING <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) J. <br /> ft. <br /> 7t) f <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location Casing type � <br /> Blank ft. Screen <br /> Slot size <br /> CIZ Z7 <br /> GROLMNG Bags cement <br /> Buckets bentonite <br /> Depth to water Z o 5 6 c Bags sand/gravel 5 & <br /> Mix Ratios M< Filter Pack type/size 173 <br /> ipstallation Method Surge Block: - (y/i ) <br /> Quantity Installed Discussed with geologist: - V/ n <br /> Type of method — <br /> EH 29 29. . <br /> t. <br />