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MONITORING WELL INSTALLATION REPORT <br /> DateCONSTRUCTION <br /> : I't-- � �� \ b� <br /> 0 P,tc S L,-/ Ca'�^ Total Depth <br /> Premise Address: �^- Screen Length (from)._ (CO) <br /> Filter Pack (from) (to) <br /> Well No.: Bentonite (from) (to)— <br /> C� ��,/�^,D-« Grout (from) (L0) <br /> Inspector. Drilling rig type <br /> Auger O.D. /0 I.D. T2 <br /> Permit No. Completion - Stove pipe/chrisde box (circle one) <br /> Drilling Company: � <br /> casing <br /> Driller.• –:F height <br /> Consultant h v <br /> Geologist ABOVE-GRCUND :STY-3CX <br /> CO MV LETfO N CoMPL='-ICN <br /> --Cirouc�d Barad <br /> SPECIAL PERMITINFO- g(Cut <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - �. _ <br /> SAMPLING socicn <br /> vavv�Pack <br /> Holding Temperature <br /> Method = <br /> Screening Method <br /> Tracking Sheet - (y/ n) 7� <br /> SPOILS <br /> MATERI ALS/DEVELOPMENT <br /> Storage Method U <br /> Contamination Noted - (Y/ n) Casing type �� L S�` L <br /> Storage Location Blank S" <br /> S ft- Screen /6 <br /> Slot size •F 2 d <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Q.� Filter Pack type/size 3 — <br /> Mix Ratios .� Surge IIlock: - (y/n) <br /> Jpstallation Method Discussed vrith geologist: - (y/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />