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MONITORING-WELL INSTALLATION REPORT <br /> Date:_ 11I1d{ py CONSTRUCTION <br /> Premise Address: W�I f fnr 7{ Total Depth 3 S <br /> Well No.: Screen Length (from) <br /> Filter Pack (from) (to)�_ <br /> Inspector. _ Bentonite (from) (to)� <br /> Grout (from) (to)�_ <br /> Permit No. Drilling rig type' <br /> Auger O.D.' I.D. <br /> Completion - Stove pipe/cluistle box (circle one) r <br /> Drilling Company;-- `�,�. ��� . <br /> Driller:_ - /�1 d ('G, <br /> Consultant t) <br /> Geologist_ sC.o4 <br /> 1© <br /> SPECIAL PERMIT INFO. it.groutseal <br /> Distance to sewer line <br /> ft <br /> Domestic well on site - (y <br /> If yes, location and d' ,nce - <br /> gravel pack <br /> . . p <br /> SAMPLING VA- - - <br /> Screening <br /> Holdng Temperatu,r-re.�v <br /> seal <br /> Method <br /> Method <br /> Tracking Sheet - (y/ n ) ) ft• <br /> gravel pack <br /> SPOILS <br /> 5 ft. <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - k7 n) <br /> Storage Location ty# p Casing type PV e'r <br /> Blank-ft. Screen fr. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water w23 Bags sand/gravel <br /> MiX Ratios Filter Pack type/size-t5 5 _ <br /> -installation Method. .,j Surge Block: - (y <br /> Quantity Installed Discussed vAth geologist: - (y/ n ) <br /> Type of method <br /> EH 29.29• . <br />