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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> 4Z <br /> Premise Address: //YO Total Depth <br /> Screen Length (from) (to) <br /> Well No.: �'`�'� S � __ Filter Pack (from) (to) <br /> / Bentonite (from) (to) <br /> Inspector. �[ Grout (from) (to) <br /> Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: F height <br /> It[M7 IV _qV <br /> Consultant — � LITA <br /> ��� <br /> Geoll*st '//''' fi Ov' �,'ZVE-GRCUND <br /> h fP L_cT b N Ct_i:STY-30X <br /> CO <br /> cC+APt_mcN <br /> SPECIAL PERMIT INFO. Gr«,na suiacs <br /> gree, <br /> Distance to sewer line - <br /> Domestic well on site - (y/ n ) «• <br /> If yes, location and distance - �• <br /> ft. <br /> V' M <br /> O <br /> SAMPLING sQcicn — <br /> Holding Temperature2LV <br /> Method =� _ <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) — <br /> SPOILS <br /> Storage Method MATE RIALS/DEVEI OPMENT <br /> Contamination Noted - (y/ n ) Casing type <br /> Storage Location Blank ft. Screen h <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> r _ Bags sand/gravel <br /> Depth to wate ---- <br /> Mix Ratios Filter Pack type/size <br /> - installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist. - ( y/ n ) — <br /> Type of method <br /> EH 29.29 <br />