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MONITORING WELL INSTALLATION REPORT <br /> Date: �� I Z- CONSTRUCTION <br /> 5T-r(/ (.>pY� Total Depth <br /> Premise Address: �y Sween Length (from) (to) <br /> Well No.: 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: ! �7F height <br /> Consultants –r <br /> Geologist / "k rJ� l�,' �P I CM 'd�^J — - T <br /> � ABOyE1�CUND Ct6ii5'iY-30X <br /> COMPLETION <br /> Grou <br /> SPECIAL PERMIT FO. �Suint <br /> IN + <br /> 10, grout <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) tt° <br /> If yes, location and distance - tt <br /> tt. <br /> C <br /> O <br /> tlonad 7E <br /> SAMPLING tacicn = <br /> Holding Temperature = yr'valtc <br /> Method <br /> Screening Method <br /> Tracking Shcet - (y/ n ) _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVEI OPMENT <br /> Contamination Noted - (y/ n) Casing type p – <br /> Storage Location Blank fc. Screen. <br /> Slot sizo <br /> GROUTING Bags cement <br /> 77 ( Buckets bentonite <br /> Depth to water / /y � ) Bags sand/gravel <br /> De <br /> P Filter Pack type/size <br /> Mix Rados Surge Block: - ( y/ n ) <br /> Installation Method Discussed with geologist: - (y/ n ) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />