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., t: <br /> MONITORING WELL INSTALLATION REPORT ' '+ <br /> (�. ''. Q <br /> Date: CONSTRUCTION <br /> Premise Addres • Total Depth r <br /> ` Screen Length (from) (to) <br /> ',Well No.: W' �, _ Filter Pack (from) (ta) <br /> - Bentonite; (from) (to) <br /> Inspector. F6 � ;Grout ' (from) 63 (t 0) <br /> Drilling rig type _'sn <br /> Permit No. Auger O.D. <br /> Completion - Stove pipe,/Cu box circle one) <br /> Drilling Company:••� iY c 1T '' <br /> 33 <br /> Driller: �l�ail ,c9�, „r casing <br /> he_ght. <br /> Consultant G�1 -7r <br /> Geologist <br /> r AEFC1 -GRCUND <br /> COtvPLETIO(t C/rH�RLT� 43/O�X <br /> - <br /> L=n VN ' <br /> SPECIAL PERMIT INFO. l' ' Ground Surface <br /> 3r <br /> Distance to sewer line l <br /> Domestic well on site - ( y/ n ) ft. <br /> If yes, Iocation and distance - f <br /> SAMPLING ;; tbroi <br /> A <br /> 21 c `H . <br /> Holding Temperature cK <br /> Method . r <br /> Screening MetKod <br /> Tracking Sheet y n ) f & <br /> t <br /> ` � <br /> SPOILS r �. • ! <br /> Storage Method MATERIALS EWI.OPMENT l <br /> Contamination Noted y n ) '311 <br /> Storage Location O d � Casing type 4Z�__ <br /> 7 . <br /> Blank ft. Screen 45 fr <br /> Slot size I r 0j5> <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/ <br /> Quantity Installed Discussed'.with geologist: — / n ) <br /> Type of method <br /> EH 29 29 <br />