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MONITORING <br /> NITORING WELL INSTALLATION REPORT' <br /> 4j) 6 Z. CONS ON <br /> Date: ,�I <br /> fur-- 6(DI Sv� Total Depth bs .S <br /> Premise Address: Screen Length (from) D$• (to)—� -- <br /> Filter Pack (from)16 (C0)� — <br /> Well No.: / Bentonite (from) tis -O (CO) <br /> l� �< v a c ', Grout (fro ) 5?.� (to) <br /> Inspector. t Drilling rig type S z <br /> Auger O.D. /D° I.D. 4 <br /> Permit No. Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: l US e( <br /> casing <br /> Driller: 017M JF height <br /> Consultant <br /> Geologist AgpVE-GRCUND C'�S*Ty-acx <br /> CCMPL_ETION ccmPL—nCN <br /> G=rd Satan <br /> SPECIAL PERMIT INFO. <br /> prart ct 3.5 6,. Is- <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - ft — <br /> _ - m <br /> C <br /> SAMPLING t cic <br /> tocicn _ <br /> ¢avd pack <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) _ tt <br /> ft. <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method <br /> Contamination Noted - (y/ n ) Casing type <br /> Storage Location Blank--11.S--ft- Screen ID K• <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Ratios Surge Block: - ( y/ Il ) <br /> Installation Method Discussed with geologist: - (y/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />