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MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> Total Depth <br /> f/ <br /> CONSTRUCTION <br /> Premise Address:/I )r6 1� � <br /> Screen Length (from)23 (to) v <br /> b(ob Filter Pack (from) � (to) <br /> SS <br /> Well No.: Bentonite (from)�Uo) <br /> Grout (from) <br /> Inspector. K Drillingrig typ (to) 't <br /> g e <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: � height <br /> Consultant —EW <br /> Geologist G/l�1 �� ABOVE-GrGCUND <br /> C4-RISTY-30X <br /> CCWLETCN COWPUMON <br /> ®o Ground SLrixs <br /> SPECIAL PERMIT IN <br /> 2°1 5 au, Orwt <br /> Distance to sewer line 32, <br /> Domestic well on site - (y/ n ) 0 sew, ft. <br /> If yes, location and distance - tt' <br /> Sa ''78 tt <br /> — a <br /> = m <br /> _ P <br /> C <br /> ilorad � <br /> SAMPLING SNS turicn <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet • (y/ n) _ <br /> SPOILS <br /> MATERI ALS/DEWLOPMENT <br /> Storage Method <br /> Contamination Noted - (y/ n ) Casing type 7 ���!/ � p/ <br /> Storage Location Bl ft Screen _fc. <br /> Slot size O (3! O <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel_ <br /> Depth to water Filter Pack type/size 2-11er, -- <br /> Mix Ratios Surge Block: - ( y/ n: <br /> Installation Method Discussed with geologist: - ( y/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />