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MONITORING WELL INSTALLATION REPORT <br /> Date: /Idl U7 CONSTRUCTION <br /> Premise Address: tAl OA: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: f r "7 Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. ' Grout (from) (to) <br /> Drilling rig type <br /> Permit No. <br /> Auger O.D. I.D. <br /> • Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: _ height; <br /> Consultalu <br /> Geologist AgOyE-GSCJND <br /> coF.SPL.�c7f0 N C* -80X <br /> C001UMON <br /> --� <br /> SPECIAL PERMIT INFO. Ground Suixt <br /> pra.•t <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) It. <br /> If yes, location and distance - ft• <br /> SAMPLING slot c <br /> socicn <br /> Holding Tem er ture±b U ." _ 71 1v1 path <br /> Method = —' <br /> Screening Method i <br /> Tracking Sheet - (y/n) — <br /> � <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n Casing type �u S 4-� <br /> Storage Location Blank ft. Screen ft. <br /> Slot size - <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> ��- Bags sand/gravel <br /> Depth t water Filter Pack type/size <br /> Mix Ratios n,.f a� �'•�� Surge Block: - (y/n) <br /> Installation Method Discussed with geologist: - (y/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />