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MONITORING WELL INSTALLATION REPORT <br /> Date: ! 6 CONSTRUCTION <br /> Premise Address: _ Q ��'�..�. �. ..�i. Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter back (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: - Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. C.D. <br /> Completion - Stove pipe/cliristie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant '4 i <br /> Geologist <br /> ABCVE-GFiCtJND CHR*ry-caox <br /> COMPLETION CCWLETICN <br /> SPECIAL PERMIT INFO. (3ra.=nd S"lact <br /> grout <br /> Distance to sewer line 1 <br /> Domestic well on site - (y/ n ) T fio <br /> if yes, location and distance - . <br /> — " m <br /> q <br /> m' 4 <br /> SAMPLING <br /> J,- Y <br /> s tac cn <br /> Holding Temperature RaVW POCK <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) ` <br /> SPOILS � <,�� . �J�.VLt.K�1. vv�5� � 1Y <br /> 1 r <br /> i <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing We <br /> Blank f-t. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> r Buckets bentonite <br /> Depth to water ' ' Bags sand/gravel <br /> Mix Ratios _ _.__ Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Insralled Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />