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MONITORING WELL INSTALLATION REPORT <br /> Date: I I V� I CONSTRUCTION <br /> Premise Address: i 7 Total Depth 2: <br /> Screen <br /> Screen Length (from) (to) <br /> Well No.: � ^ ` (Act Filter Pack (from) (to) <br /> Bentonite (from)�(to)— <br /> Inspector. <br /> from) (to)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: � 7 -:F height <br /> Consultant 1<-C.�il •Z- <br /> Geologist ABOVE•GRCUND <br /> COMPLETION Ct O <br /> PLEDN <br /> CCliMPL-?71CN <br /> Grou <br /> SPECIAL PERMIT INFO• rd Suixt <br /> ptaA <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) (t. <br /> If yes, location and distance - tt <br /> tt. _ <br /> - C <br /> slorwi <br /> C <br /> SAMPLING �gU IL socicn — <br /> Holding Temperature) <br /> ti. <br /> Method <br /> Screenin;Method M — <br /> �� <br /> Tracking Sheet - (y/ n) 1ti — tt. <br /> SPOILS <br /> Storage Method p MATERIALS/DEVELOPMENT <br /> Contamination Noted- (y/ ) Casing -o o Ff & <br /> Storage Location Blank g Screenft. <br /> Slot size <br /> GROU I1NG Bags cement <br /> Buckets bentonite <br /> Depth to water �' S� Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> .Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br />