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MONITORING WELL INSTALLATION REPORT <br /> Date: I I ? y�l CONSTRUCTION <br /> Premise Address: N � > L t/Ir, ��✓v+W Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: M tTV I Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: � casing <br /> Consultant � o s / height <br /> Geologist ,ty"4r •- T <br /> A80VE-aACUND CHR*_Y-80X <br /> COMPLETION COMPLEMN <br /> SPECIAL PERMIT INFO. Ground SuAan <br /> Distance to sewer line Qrcut <br /> Domestic well on site - (y/ n) <br /> ft. <br /> If yes, location and distance - <br /> ft. <br /> R. <br /> - e <br /> SAMPLING slorad = c <br /> sor*cn — <br /> Holding Temperature gaud F <br /> Method <br /> Screenin;Method —_ <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> 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 /> Installation Method Surge Block: - ( y/ a ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />