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MONITORING WELL INSTAL I ATION REPORT <br /> Date: <br /> CONSTRUCTION <br /> Premise Address.4 -� <br /> / Total Depth <br /> Well No.: ( trJ-1/5f—I r 1 2/SP 7 Screen Length (from) <br /> Filter Pack (from)- ----(to)�� <br /> Inspector. t Bentonite ----�(to) <br /> 7CAnn!'r� i <br /> Grout o)'---=---(to)- <br /> PermitNo. ( Drillin -- (CO)_�^ <br /> 3ngtype <br /> Drilling Compan Com° 1 O.D. �n 1'p-- I.D. <br /> - ----_ <br /> P Stove i e duistie box (circle one) <br /> Driller' <br /> Consultant <br /> i 1 <br /> Geologist, _ p <br /> E <br /> SPECIAL PERMIT INFO. /— grout <br /> - - -�-12ft. <br /> / <br /> Distance to server line 15 ft seal <br /> f _ ft. <br /> Domestic well c site y/n) <br /> If yes, location an istance - <br /> gravel pack <br /> SAMPLING - - - Lft. <br /> HoldIngTemperature n v, �"Q,J seal <br /> Method 1 <br /> Screening Method - - <br /> Tracking Shcet - (y/n ) ft: <br /> gravel pack <br /> SPOILS yft. <br /> Storage Method <4 Aa cry, i <br /> MATERIAIS/DEyEL OPMEN[ <br /> Contamination Noted y n) <br /> Storage Location Casing type <br /> Blank <br /> fr Screen fr. <br /> GROUTING Slot size <br /> Bags cement <br /> Depth to water 6`T 2 C� .a Buckets bentonite_, <br /> MiX Ratios Bags sand/gravel <br /> installation Method Filter Pack type/size_ <br /> -��^ I (y/(-Ir) <br /> Surge Block: - (y/ <br /> Discussed with geoT6gist: - (y1-n <br /> EH 29 29 Type of mediod <br />