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MONITORING WELL. INSTALLATION REPORT <br /> Dater�;/ ;� i rsL CONSTRUCTION <br /> Premise Address: ' k b°o 4r Total Depth <br /> Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Well No.: Bentonite (from) (to) <br /> Inspector. Grout rig (from) (to) <br /> a a tyP <br /> Auger O.D. LD. <br /> Permit No. Completion - Stove pipe/cltristie box (circle one) <br /> Drilling Company: <br /> Y_ casing <br /> Driller: height <br /> � L/I LtGtl� vQ�✓ <br /> Consultant –I <br /> Geologist ABCVE-GRCUND ply gpX T <br /> CON'LETION COMPLETION <br /> SPECIAL PERMIT INFO. Sul + <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - ( y / n ) It, <br /> If yes, location and distance - ft <br /> ft. <br /> we <br /> a <br /> c <br /> SAMPLING donwi <br /> s. cn —_ <br /> wwwwww <br /> Holding Temperature _ pavdTaCSc <br /> Method — <br /> Screening Method <br /> Tracking Sheet - ( y / n ) <br /> tt. __• — ft; <br /> SPOILS <br /> Storage Method <br /> MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y / n ) <br /> Storage Location Casing type _ft. <br /> gl� ft. Screen <br /> Slot size <br /> GROUTLNG Bags cement <br /> Buckets bentonire <br /> DBags sand/gravel <br /> Depth to water <br /> Filter Pack type/size <br /> Mix Ratios <br /> Surge Block: - ( / it <br /> Installation Method ) <br /> ailed Discussed with geologist: - ( y / n ) <br /> Quantity Ins[ Type of method <br /> EH 29 29 <br />