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MONITORING WELL INSTALLATION REPORT <br /> Date: Lit 12110�1 // rr CONSTRUCTION <br /> Premise Address: 3 Z� b�c�a as l Total Depth <br /> Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Well No.: p Bentonite (from) (to) <br /> Grout Inspector, iQ�` ^�" Drilling rig type(from) (to) <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: °a �° � he_ght <br /> Consultant - ` <br /> Geologist � !' JBOVEGRCUND CtASr7 X <br /> SPECIAL PERMIT INFO. �—Cxard Suf=I <br /> prat <br /> Distance to :ewer line _ 1I <br /> Domestic well on site - (y/ n) - ft• <br /> If yes, location and distance - ft <br /> 0 <br /> I � M <br /> O <br /> C <br /> O <br /> SAMPLING soricn ' y; <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n) " = ft. <br /> SPOILS <br /> MATE RI ALS/DEVELOPMENT <br /> Storage Method N PJf/ <br /> Contamination Noted - (y/ n) Cuing type 7• R• <br /> Storage Location Blank fc Screen_____� <br /> Slot size O• ZO <br /> Bags cement <br /> GROLMNG Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size Z, l7 f <br /> Mix Ratios Surge Block: - (y/n) <br /> .installation Method Discussed With geologist: - (y/ n) <br /> Quantirylnstalled Type of method ----- <br /> EH 29 29 <br />