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`MONITORING WELL INSTALIATION REPORT <br /> f 5 <br /> Date. f> C t CONSTRUCTION~ <br /> Premise Address:' ( �' 1 i"" ""�"''� Total Depth <br /> J Screen Length (from) (CO) <br /> Well No.. t ?"13, 4� "C' Filter Pack ,(from) (to) <br /> Bentonite (From) (to) <br /> inspector. 7R ./}' -� - Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. LD. <br /> Completion - Stove pipe/christie box (circle-one) <br /> Drilling Company: <br /> Driller• <br /> casing ` ' t <br /> he=ght <br /> Consultant Y <br /> Geologist AB"OVE GM Nl1CIO <br /> W[fir V-G..1 ON - COM LE i O t <br /> SPECIAL PERMIT INFO. R Ga.rrd Suiacs <br /> Distance to sewer line Qra�t <br /> ,,.,Domestic well on site - (y n) s _. <br /> If yes, location and istance = . <br /> tt. <br /> SAMPLING stcra.1 <br /> •Y <br /> _ socicn - <br /> Holding Temperature .~ _ <br /> paY�l Pacrc <br /> Method = _ <br /> Screening Method , <br /> Tracking Shcet. {y/ n) <br /> .,_..�tt. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> a Location Casing type <br /> -Storage Blank ft- Screen fT• . <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> 4ristallation Method Surge Block: - (y/n ) <br /> Quantity Installed Discussed vAth geologist: - (y/ n ) <br /> Type of rnediod <br /> EH 29 29 <br />