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NITORING WELL INSTALLATION REPOR' <br /> Date: _ CONSTRUCTION / <br /> Premise Address: Total Depth r/J LI <br /> —7 Screen Length (from) to ' (to)_ <br /> Well No.: 1A 1 Filter Pack (from) y —(to) 3- <br /> Bentonite (from) L4, (to) • S ' <br /> Inspector. Grout (from) 4 D: S ' (to) <br /> Drilling rig type <br /> Permit No. u ` D Auger O.D. 17 <br /> D U <br /> Completion - Stove pipe/c box (circle one) <br /> n <br /> Drilling Company: � ryLC� to — " <br /> Driller. �� easing <br /> 7r7 <br /> height <br /> Consultant ' 2 0.X + T <br /> T <br /> 75 <br /> Geologist 0400 <br /> AWYEwGROUND <br /> COWLEr10N OOMPI._°TIOMP ErcX <br /> CN <br /> SPECIAL PERMIT INFO, G=nd Susan <br /> Distance to sewer line arart <br /> Domestic well on site - ( y nl It. <br /> II If yes, location and distan g, <br /> ."L.ft. <br /> M3 <br /> - o <br /> SAMPLING alarmed = � <br /> wcdon <br /> Holding Temperature gravel pads <br /> Method r It\ AlcR f , _ In . Z O <br /> Screening Method M% = <br /> Tracking Sheet - ( y / n ) _ tL <br /> SPOILS �— <br /> Storage Method J > C/ j�' t MATERiALS/DEVELOPMENT <br /> Contamination Noted • y <br /> Storage Location ? IDfu ° Casing type <br /> avw^ Blank7 fr. Screen ft. <br /> /v Slot size `7� <br /> GROUTING Bags cement <br /> Buckets bentonite ]2 <br /> Depth to water J Bags sand/gravel <br /> Mix Ratios Filter Pack type/size 41( A �s R9 <br /> Installation Method h m a Surge Block: - ( y / a ) <br /> Quantity Installed Discussed with geologist: - ( y / n ) <br /> Type of method <br /> EH 29 29 <br />