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< T <br /> MONITORING WELL INSTALLATION REPORT <br /> Dater I �•� CONSTRUCTION <br /> Premise Address: � � . SIP Slec /¢CP Total Depth c2S <br /> Screen Length (from) Ad (to) <br /> Well No.: %w z Filter Pack (from) 2 (to) Z 5— <br /> Bentonite (from) Y <br /> Inspector. (/�� Grout (from) / —(to)�— <br /> Drilling rig type ' ' 2; <br /> Permit No. Auger O.D. /O I.D. <br /> Completion - Stove pipe/duistie box (circle one) <br /> Drilling Company: <br /> Driller: L —«ter 41e ✓ IFm <br /> casing <br /> // height <br /> Consultant L�- -, 1z�5 �'� . <br /> Geologist (i " l � / { ` <br /> A°AVE-GRCUND <br /> CCWLETfON ctv"ASI7-Box <br /> C_C+APUET1CN <br /> SPECIAL PERMIT INFO. G=nd S rtac+ <br /> Distance to server line groat <br /> Domestic well on site - ( y / n ) __ (t. <br /> If yes, location and distance - ft <br /> ft. <br /> SAMPLlN6 slor.A.i = � <br /> socicn -_ <br /> Holding TemperaturePack <br /> Method = <br /> Screening Method = <br /> Tracking Sheet - ( y / n ) <br /> ft. L= = ft. <br /> SPOILS <br /> AY <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y / n ) Ti44 , e'6 ILLI � - TW, 1 ( <br /> Storage Location Casing type <br /> Blank ft. Screen h• <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> ipstailation Method Surge Block: - ( y / n ) <br /> Quantityinstalled Discussed vrith geologist: - ( y / n <br /> Type pf method — <br /> EH 29 29 <br />