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MONITORING WELL INSTALLATION REPORT <br /> r <br /> Date: I-tTl { J o -C CONSTRUCTION <br /> Premise Address: Total Depth <br /> Well No.: 01-i -I <br /> Screen Length (from) (to) <br /> SP-16 t 'fJ )��SR/� Filter Pack (from) (to) <br /> Bentonite (from) (toj <br /> Inspector. _ D tAA, rc. Groue (from) (to) <br /> Permit No. L-/1 Lf S V Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Company; <br /> Completion - Stove pipe/cluistie box (circle one) r <br /> Driller:_-_ lgwwn(o� . <br /> Consultant_. tJ 12S <br /> Geologist_ SLrr� fcvv.c (tee-( <br /> grout <br /> SPECIAL PERMIT INFO. ft.seal <br /> Distance to sewer line Lft. <br /> Domestic well on site>k-fl n ) <br /> If yes, location and stance - " <br /> gravel pack <br /> SAMPLING r- - - — <br /> seal <br /> Holding Temperaturey•cd'/rnniG <br /> e 35 <br /> Method T4nnc-fr - ' nlsSsfE.w• - - - - - - — <br /> Screening Method 14 10 <br /> Tracking Sheet ( / n ) <br /> gravel pack <br /> 3 g ft.. <br /> SPOILS <br /> Storage Method_ Yo LO MATERIALS/DEVELOPMENT <br /> Contaminadon Noted - *-Y n) <br /> Storage Location Casing type I " t>/C 2 <br /> Blank fc. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water ^� L 3 �i Bags sand/gravel <br /> Mig Ratios Filter Pack type/size at"4^ <br /> -installation Method � � Surge Block: - (y/n ) <br /> Quantity installed Discussed vAth geologist: - (y/ n ) <br /> Type of mediod <br /> EH 29 29 <br />