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MONITORING WELL INSTALLATION REPORT <br /> q D� pv CONSTRUCTION <br /> Date: / <br /> ry� ��r , �� st C Total Depth <br /> Premise Address: r Screen Length (from) (to) 5 <br /> Well No.: Filter Pack (from) (to) <br /> f�, Bentonite (from)_T—Ro) <br /> Inspector. Uk. btA Grout (from).(W) <br /> Drilling rig type <br /> R nC� Z� Auger O.D. I I.D. C, <br /> Permit No. Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company n-c4f <br /> �� casing <br /> Driller: height <br /> Consultant �`r C�a! <br /> e — T <br /> Geologist 1 c~ AZ0VE•GRCUND cl-iszT1•-80X <br /> CONFLEfION COMPLETICN <br /> Ground <br /> SuAx" <br /> SPECIAL PERMIT INFO. t <br /> prat <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - ft. <br /> w <br /> - o <br /> 0 <br /> dotoi � <br /> SAMPLING soc'cn = S <br /> Holding Temperature <br /> Method <br /> Screenin;Method — <br /> Tracking Sheet • (y/ n) <br /> �ft. <br /> SPOILS <br /> Storage Method MATERIALS/DBVEI OPMENT <br /> Contamination Noted - (y/ n) Casing type 2- <br /> Storage Location Blank ft Screen b fr• <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water <br /> Mix Rados Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ tt <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />