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MONITORING WELL INSTALLATION REPORT <br /> Date: t?; /L — !7 p/ CONSTRUCTION <br /> Premise Address: � � Total Depth_ <br /> Screen Length (from). _(to) <br /> Well No.: Filter Pack (from) 7 P —(to) 3 <br /> Bentonite (from)_ 3 (to) CIT <br /> Inspector: Grout (fromI- —(to) <br /> �7� � Drilling rig type �- <br /> Permit No. Auger O.D. <br /> '- Completion - Stove pipe/ je dircle one) <br /> Drilling Company <br /> Driller: casing <br /> T height <br /> Consultant <br /> Geologist <br /> AYE-GR CUND G-1MM-aoX <br /> OOMPLE' ON COMPLEnON <br /> SPECIAL PERMIT INFO. Ground Sudact +"" --�� <br /> Distance to sewer line grout <br /> Domestic well on site - (y 1,eo ft. <br /> If yes, location and distance - Z._ n, <br /> ft. <br /> s: m <br /> 0 <br /> SAMPLING flared — <br /> �/ aaczcn <br /> Holding Temperature (� �r,vei Fade <br /> Method <br /> Screening Method 1PI3 .= <br /> Tracking Sheet - (y/ n ) — <br /> tt. <br /> SPOILS <br /> Storage Method C3^ MATERIALS EVELOPMENT <br /> Contamination Noted - (y/4} �y <br /> Storage Location — Casing type <br /> Blank rg~ ft. Screen /Z'' ft• <br /> Slot size <br /> GROUTING Bags cement <br /> / r Buckets bentonite <br /> Depth to water « 6 Bags sand/gravel <br /> Mix Ratios /o_/ Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed ` r Discussed with geologist: - ( y/ n } <br /> Type of rnechod <br /> EH 29 29 <br />