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MONITORING WELL INSTALLATION REPORT <br /> f <br /> Date: CONSTRUCTION <br /> e <br /> Premise Address: X r, rc U�, e Total Depth C1 O <br /> Screen Length (from)C5 ' (to) <br /> Well No.: Im W-(r( Filter Pack (from) sZ (to) 4o y <br /> Bentonite (from) 4-U L <br /> (to) g <br /> Inspector: I�cwnncu Grout (from_ ) ��(to) go <br /> Drilling rig type <br /> Permit No, Auger O.D. I.D. <br /> Completion- Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller:— A 1,,,__ i casing <br /> Theight <br /> Consultant /� T C II <br /> Geologist <br /> ABOVE-GROUND CNAISTY-BOX <br /> COMPL�ION COMPLETION <br /> SPECIAL PERMIT INFO. Gmund Surface <br /> Distance to sewer line_ Gt1 � <br /> Domestic well on site - n) T� fO ft <br /> If yes, location distance <br /> ' qT` <br /> 9 <br /> SAMPLING 810L _ s <br /> Holding Temperature = P <br /> Method <br /> Screening Method p 1 0 <br /> Tracking Sheet - ' n) <br /> SPOILS <br /> Storage Method_ MATERIALS/DEVELOPMENT <br /> Contamination Noted no <br /> - <br /> Storage Location n-%A4 t E7( Casing type Z PVC <br /> Blank �ft. Screen S ft. <br /> Slot size - 010 <br /> GROUTING Bags cement /'Z V <br /> Buckets bentonite <br /> Depth to water 41,; l Bags sand/gravel <br /> Mix Ratios 4 is�. Q nln,. _ , Filter Pack type/size -,t,/tom- <br /> Installation Metho eynnn w A Surge Block: - (y/ <br /> Quantity Installed_ ti Z i n I Discussed with geologist: - (y <br /> EH 29 29 Type of method <br /> d <br /> `i <br />