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MONITORING WELL INSTALLATION REPORT <br /> Date: 1 I v -7 CONSTRUCTION <br /> Premise Address; &"1 4&e-�7 Total Depth_ <br /> Well No.: m 1 V Screen Length (from) �Z E) (to) <br /> Filter Pack (from) ,2 6 ,(, (to) 1/ <br /> Bentonite (from) •3 /U�� (to) <br /> Inspector: f 2i ( � Grout (from)_ (to) <br /> Drilling rig type �Lo(�0^t J C-/Y^ <br /> Permit No. Auger O.D. 2 '/y I.D. <br /> Completion e o (circle one) <br /> Drilling Company: la u n-, <br /> Driller: casing <br /> height <br /> Consultant_ <br /> Geologist <br /> ABOVE-GROUND <br /> COMPLETION CNRtSTY-8OX <br /> SPECIAL PERMIT INFO. Ground Surface COMPtET10N <br /> Distance to sewer line Ori <br /> Domestic well on site - (y/n ) 1 ft- <br /> If yes, location and distance - h <br /> ' — m <br /> SAMPLING — o <br /> totted d <br /> taction — <br /> Holding Temperature <br /> Method ` _ 7" t <br /> ack <br /> Screening 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 <br /> Slot size ©I <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/n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />