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MONITORING WELL INSTALLATION REPOxT <br /> Date: CONSTRUCTION <br /> 4 <br /> Premise Address: " 2.'D Total Depth (iO <br /> Screen Length (from) (to) it n, <br /> Well No.: 111M(k) Ss Filter Pack (from) to)- I 1 n` <br /> Bentonite (froth) (to) <br /> Inspector. Grout (from)- $ (to)_ 15, <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/ciiristie box (circle one) <br /> Drilling Company: \/ � t%) h-x A f AA,. <br /> Driller. casing <br /> height <br /> Consultant M11 'V <br /> GeoIogist .� <br /> IWv1:-GAcuNo CHSZTY-BOX <br /> COWLS ICN CCMPL—=nCN <br /> SPECIAL. PEANUT INFO. G=ro d S =0 <br /> Distance to sewer line groat <br /> Domestic well on site - ( y/ n) L ft. <br /> If yes, location and distance - <br /> 0o ft. <br /> 4 O <br /> y, <br /> O <br /> SAMPLING siaGo.� <br /> secicn t' <br /> Holding Temperature LUXA c.z g"„ Pack <br /> Method L," <br /> Screening Methodein <br /> ' <br /> Tracking Sheet y n ) <br /> .a: <br /> 1 Ift. <br /> SPOILS <br /> Storage Method ov., GA_O%4 MATERIALS/DEVELOPMENT <br /> Contamination Noted - y n ) <br /> Storage Location oy" rfr A Casing type <br /> Blank ft. Screen <br /> Slot size .b 10 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method p nQ. .4-i,.... Ule Surge Block: - (V n ) <br /> Quantity Installed- iu d QWA 1112V7 Discussed with geologist: - n ) <br /> Type of mcthod_,Lji_._ <br /> EH 29 29.... <br />