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" i <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address : 3/ `/ 7 Total Depth t/ O <br /> Screen Length (from) r-/ 0 (to) z� <br /> Well No. : /hW6 Filter Pack (from) L/ c7 (to) <br /> Bentonite (from) P K (to) <br /> Inspector: COSGrout (from) 77 <br /> ! 6 (to) <br /> Drilling rig type/ <br /> Permit No. Auger I.D. <br /> Completion - Stove pipe/dtristie box (circle one) <br /> Drilling Company: AV�.Cvo <br /> Driller: f (�/ casing &LEn <br /> Qa � height <br /> Consultant 5 yiGeologist G S yE-GROUND WLETION <br /> SPECIAL PERMIT INFO. nd Sixtan <br /> grout <br /> Distance to sewer line JJ <br /> Domestic well on site - ( y / n ) ! o It• <br /> If yes, location and distance - tt- <br /> Y� ft. <br /> = a <br /> - C I <br /> SAMPLING dorted _ <br /> sucicn — 3 <br /> Holding Temperature = pavd Wdt <br /> Method = <br /> Screening Method <br /> Tracking Sheet - Cy / n ) <br /> I <br /> SPOILS <br /> Storage Method i0w av✓g MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y / n ) rr <br /> Storage Location !' � S '� Casing type <br /> Blank �! ft. Screen Z�r ft• <br /> Slot size rsi 8 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water <br /> . i Bags sand/gravel <br /> I <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (�/ n ) <br /> Quantity Installed Discussed with geologist: - ( y / n ) <br /> Type of method �e <br /> EH 29 29 <br />