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AvITORING WELL INSTALLATION REPOR'• <br /> Date: —7 1 l CONSTRUCTION <br /> Premise Address: 3'l� an Total Depth <br /> Screen Length (from) > (to) <br /> Well No.: rn �j I Filter Pack (from) _} l (to) <br /> / Bentonite (from) <br /> Inspector:�� ' / - Grout (from) z . 7 ' (to) tt CL <br /> J lDrilling rig type <br /> Permit No. 10✓J�,, Auger O.D. <br /> d Completion - Stove pipe •sae box (circle one) <br /> Drilling Company: <br /> Driller: T casing <br /> T he±ght <br /> Consultants <br /> Geologist / rA Y— A80VE-GRCUNO <br /> C01�L=fiON C'HRZ Y-30X <br /> CCMPLFnCN <br /> SPECIAL PERMIT INFO. Ground Strlap — <br /> Distance to sewer line S a/ grout <br /> Domestic well on site - (y/(n-) <br /> If yes, location and distance - 7� tL <br /> ft. <br /> = m <br /> _ <br /> = o <br /> SAMPLING dor J <br /> soden <'• <br /> Holding Temperature <br /> Method <br /> Screening Method _ <br /> Tracking Sheet - ( y/ n ) <br /> n. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) 1' 0 v r <br /> Storage Location Casing type 7 <br /> Blank 9• ,S ft. Screen i •S ft. <br /> Slot size <br /> GROUTING Bags cement h <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method a e Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />