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i <br /> MONITORING WELL INSTALLATION REPORT <br /> I <br /> i <br /> Date: 7lei [ 01 CONSTRUCTION <br /> Premise Address: Std ]JrLnTotal Depth S <br /> Screen Length (from) Ibo' (to) <br /> Well No.: Filter Pack (from) RS (to)—1 I,S ' <br /> Bentonite (from) h (to) cl t I <br /> Inspector: Grout (from) (to) A <br /> Drilling rig type <br /> Permit No, Auger O.D. I.D. <br /> Drilling Company: �-�� Completion - Stove pipe/clu istie box (circle one) <br /> . �-� ,( ,�, nn,. <br /> Driller: �int/t�l� casing <br /> height <br /> Consultant � <br /> Geologist `icg-A4 <br /> ABOVE-GROUND CttA15TY20X <br /> COI.PLETION COWLEnCN <br /> SPECIAL PERMIT INFO. Ground Surf <br /> Distance to sewer line V, grout <br /> Domestic well on site,{y/ n ) <br /> If yes, location and distance - tt. <br /> SAMPLING <br /> slarai — c <br /> socicn <br /> Holding Temperature <br /> Method — <br /> Screening Method <br /> Tracking Sheet - (y/ n ) _ <br /> ft. <br /> SPOILS <br /> Storage Method f Inti MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( /n ) <br /> Storage Location_ CN\ e,( bk. ' Casing type 9-„ eve- <br /> Blank I O© ft. Screen / 5 ft. <br /> Slot size ' 02-0 <br /> GROUTING Bags cement <br /> Buckets bentonite 3 4 <br /> Depth to water Bags sand/gmvcl z <br /> Mix Ratios L " e �w(�(� Filter Pack type/size #? 4-ot„o <br /> Installation Method•T AA&T P1 _17 - cj'l Surge Block: - (y/ a ) , <br /> Quantity Installed Discussed with geologist: - ( y Cn <br /> EH 29 29 Type of method <br /> u r <br />