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MOIQITORING WELL INSTALLATION REPORT• <br /> Date: l 9 y� CONSTRUCITON <br /> Premise Address: ��/�//a G S ��t�' Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. L�7 Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cltristie box (circle one) <br /> Drilling Company: <br /> Driller: c as i nq <br /> �� height <br /> Consultant <br /> Geologist <br /> ABOVE-GACUND CHAISTY 80X <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surfact <br /> Distance to sewer line PIZ <br /> grout <br /> Domestic well on site - (y/ n ) ft. <br /> If yes, location and distance - ft. <br /> h. <br /> SAMPLING sloped E <br /> asc'cn <br /> Holding Temperature = t Y�F'cK <br /> Method _ <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> ft. IF = ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water 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 />