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MONITORING WELL INSTALLATION REPORT <br /> Date:_ t b 13d(O "/ CONSTRUC-HON <br /> Premise Address: -5 Z} I tk64:T:in (or'- Total Depth �6 S <br /> Screen Length (from) (to)_ � <br /> Well No.: Wl(A) t5 Filter Pack (from) 'K -(to) c <br /> Bentonite (from) (� _(to)_!'aL�_ <br /> Inspector: Grout (from) (to) 6 6,( <br /> Drilling rig type <br /> Permit No. S S Z Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> �U <br /> Driller: casing <br /> height , <br /> Consultant G 1'2_ ,4 <br /> Geologist •- <br /> JEW7:F <br /> ABOVE-GACUND <br /> COM?LETION COMPLETICN <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Suriact <br /> Distance to sewer line grout <br /> Domestic well on site - <br /> If yes, location and stance - T7 <br /> Ei <br /> q <br /> C <br /> SAMPLING �lattad = c <br /> spc'aon — <br /> Holding Temperature _ P <br /> ack <br /> Method 6 'n — <br /> Screening Method 010 — <br /> Tracking Sheet - C.y n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n <br /> Storage Location Casing type PVC <br /> Blank p ft. Screen <br /> Slot size o 2.o <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size_ J <br /> Installation Method_ ��f Surge Block: - ( y/P) <br /> Quantity Installed � Discussed with geo ist: ( y/ n <br /> Type of method <br /> EH 29 29 <br />