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MONITORING WELL INSTALLATION REPORT <br /> Date:_ ! I Z S n z CONSTRUCTION <br /> Premise Address: <br /> Total Depth � 3 <br /> Well No.: NA_ (A _e� Screen Length (from)_� (to) z Z <br /> Filter Pack (from)_ _(to) I <br /> Inspector. 1111 Bentonite (from)_ q-Ts (to) _ <br /> Grout (from) (to)__ <br /> Penni[No. Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Company_�� Completion - Stove pipe/chrisrie box (cir— cls a one) <br /> Driller:� <br /> � casing <br /> Consultant � height <br /> —SE=rc��fC _ � ,� <br /> Geologist (° (� ABCVE-GRCUNDWT <br /> 00&VL TCN cl'w:STY-30X <br /> SPECIAL PERMIT INFO. c0mPLzncN <br /> CvouM Sufan <br /> Distance to sewer line , - <br /> Domestic welltte - g`� <br /> If yes, 1 on and distance0 _k �S ,- <br /> n ) <br /> It. h. <br /> SAMPLING <br /> 0 <br /> Rlocai _= c <br /> Holding Temperature soccn = <br /> Method_ �vdw <br /> Screening ck <br /> Method_ pl I ) <br /> Tracking Shcet -�y/:n ) <br /> SPOILS tt' tf. <br /> Storage Method 0";2 <br /> Contamination Noted - (Y/ n MATE RIALS/DEVELOPMENT <br /> Storage Locations, <br /> Casing type 7 ''ey� <br /> Blarilc �� it Screen_ <br /> GROUTING Slot size , o ZCI <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios y 'S7 Bags sand/gravel <br /> Installation Method HZ� Filter Pack type/size <br /> Quantity Installed Surge Block: - (y/ n ) <br /> Discussed with geologist: - ( y/ n ) <br /> EH 29 29 Type of method <br />