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MONITORING WELL INSTALLATION REPORT <br /> Date: Z CONSTRUCTION <br /> Premise Address: �� yi Total Depth <br /> .,, Screen Length (from) (to)3�' <br /> Well No.: AA-4V/� Filter Pack (from) (to)753 <br /> Bentonite (from) Z.5? (to)Zs- <br /> Inspector- <br /> sInspectorGrout (from) ? ,' _(to)1---- <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller- F6 height <br /> Consultant <br /> Geologist Ajc-vE-GRCUND <br /> CO kfP L..�T{O N Ct�1iSTY-80X <br /> COtAPLEEMON <br /> SPECIAL PERMIT INFO. Grourd Suiacy <br /> procrt r 1 <br /> Distance to sewer line ZS <br /> Domestic well on site - (y/ n) T'• <br /> If yes, location and distance - <br /> = o <br /> SAMPLING tloroi E: <br /> socicn - = <br /> Holding Temperature F <br /> ack <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/n) "— <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted- (y/n) Casing type �'1-�c/ ��c`�`L <br /> Storage Location Blanc ft. Screen ft. <br /> Slot size 0 0 1 D <br /> GROUTING Bags cement <br /> 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 vAth geologist: - (y/ n <br /> Type of method <br /> EH 29 29 <br />