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MONITORING WELL INSTALLATION REPORT <br /> -7 yI <br /> Date: L� 1 CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: IL Y Y Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion ove pip hristie box tcircle one) <br /> .Drilling Company: • u U�•'�1 Wy �, <br /> Driller: ��� casing <br /> d1, _height <br /> Consultant ; f <br /> Geologist - <br /> ASOVE-GROUND CNAISiY-BOX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n ) q Z <br /> n' <br /> If yes, location and distance - <br /> h. <br /> xv - m <br /> o <br /> SAMPLING slotted <br /> sac5on � _ <br /> Holding Temperature ; = gmvw Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/n) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) q Nc- <br /> Storage Location Casing e I <br /> Blank U"D ft. Screenh. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite 1 <br /> Depth to water Bags sand/gravel /G <br /> Mix Ratios Filter Pack type ize <br /> Installation Method Surge Block:n) <br /> Quantity Installed Discussed wi ologist: - (y/n) <br /> Type of method <br /> EH 29 29 <br />