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MONITORING WELL INSTALLATION REPORT <br /> Date : / CONSTRUCTION <br /> Premise Address: L11"otot"d Total Depth <br /> Screen Length (from) (to) <br /> Well No. :. V Filter Pack (from) ) ` (to) <br /> Bentonite (from) o (to)10000000 <br /> Grout (from) - (to),4 i cam' <br /> Inspector. ;// S <br /> Drilling rig type <br /> Permit No. Auger O.D. St `'/ LD. <br /> ,/� Completion • Stove pipe/cluistie box (circle one) <br /> Drilling Company: �� G ' <br /> Driller: I . casing <br /> height <br /> Consultant <br /> Geologist A80VEwGR0UND CHR SN*BOX <br /> coni'!ETON ccwwtrmcN <br /> SPECIAL PERMIT INFO. end Surlacs <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - ( y / n ) <br /> If yes, location and distance - fL <br /> Toil: a <br /> . c <br /> SAMPLING dorsi <br /> OC axicn <br /> Holding Tempera = graYd G <br /> Method re a =_ <br /> Screening Method <br /> Tracking Sheet - n ) i <br /> SPOILS <br /> Storage Method a MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y <br /> Storage Location Casing type <br /> Blank ato 0, 00K ft. Screen rs 0 ft. <br /> Slot size a e-0 <br /> GROUTING Bags cement <ur e <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix RatiosFilter Pack type/size <br /> Installation Method ` j.9 rKf� . Surge Block: to ( y / <br /> Quantity Installed Discussed with geologist: • <br /> Type of method <br /> EH 29 29 <br />