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MONITORING WELL INSTALLATION REPORT <br /> i <br /> Date: CONSTRUCTION <br /> Premise Address : 0 6D� lG v � ✓, � Total Depth <br /> Screen Length (from) (to) <br /> Well No.: / Filter Pack (from) (to) <br /> / Bentonite (from) ( o) <br /> Inspector. Grout (from).(to). <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: � f <br /> Driller: casing� hesght <br /> Consultant � <br /> Geologist ABCV&GRCUND Ct�itsll �OX <br /> OOWL_ET CN COWP"EnCN <br /> Grou <br /> SPECIAL PERMIT INFO. nd S�xr +�� <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - ( y / n ) tt. <br /> If yes, location and distance - ft. <br /> K. <br /> c <br /> SAMPLING 21orAi = a <br /> tut'cn <br /> /D <br /> Holding Temperature r ( _ Gr+vv� Pack <br /> Method fG _ <br /> Screening Method = <br /> Tracking Sheet - ( y / n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y / n ) <br /> Storage Location Casing type <br /> Blank ft. Screen _ <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water " > / ` ' Bags sand/gravel <br /> Mix Rados Filter Pack type/size <br /> Installation Method <br /> Surge Block: - ( y / n ) <br /> Quantity anti Installed Discussed with geologist: • ( y / n ) <br /> Type of method <br /> EH 29 29 <br />