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MONITORING WELL INSTALLLATION REPORT <br /> Date:. ?. 0 0. CONSTRUC 7ON <br /> J ` <br /> Premise Address: n + � Total Depth <br /> Screen Length (from) (to) • 7 t <br /> Well No.: — d Filter Pack (from) 3 � (to) Z.--, <br /> Bentonite (from) `_ (to)_- 31 <br /> Inspecton j'r-.-�-,jA^en i . __ _ Grout (from) (to) Z. <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: Z'U-� <br /> Driller• . casing <br /> _,..—_._.—.,.., <br /> he_ght <br /> Consultant - <br /> Geologist �, ,} <br /> A3CVE-Grr1CUND C4-Sz'TY-a0X <br /> GOI,PIET ON OO&APUMON <br /> SPECIAL PERMIT INFO. C3round s alace <br /> Distance to sewer line prcut._ m, r y. . . <br /> Domestic well on site - (y/ n ) ,- � <br /> If yes, location and distance - ft. <br /> � ft. <br /> SAMPLING <br /> tacicn �• <br /> Holding Temperature r _ <br /> Pack <br /> Method �'Y9i <br /> Screening Method <br /> 'Cracking Sheet -(a/ n ) <br /> a ft. <br /> SPOILS <br /> Storage Method c7A MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/(g>) <br /> Storage Location. Casing type­j P 1/ <br /> BIank __ _ jQLk Screen <br /> Slot size_ = 0 20- <br /> GROLMNG Bags cement < - - - <br /> ~� !H W- Buckets bentonite <br /> Depth to water �3 l •1 3 6C1 Bags sand/gravel N <br /> Mix Ratios Filter Pack type/size t4 nz 2U <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />