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MONITORING WELL INSTALLATION REPORT <br /> Date: 1 •(1 A "i CONSTRUCTION <br /> Premise Address: � Auv Total Depth <br /> Screen Length (from) tA17 (to) <br /> Well No.• Xan ' �� 1 Filter Pack (from) 1A L�_(to) 141 l 2 <br /> Bentonite (from) (to) <br /> Inspector: ��11J1'/ Grout (fr m) A(to) l <br /> P Drilling rig type <br /> Permit No. <br /> Auger O.D. I.D. <br /> n Completion ove pip Christie box (circle one) <br /> Drilling Company: <br /> ca Lng <br /> Driller: he! ht <br /> Consultant �� T <br /> T <br /> GeologistyE-GRpV <br /> CHRSST'Y-80X <br /> CQMPL"T COMPL E17CN <br /> Ground — <br /> SPECIAL PERMIT INFO. Surf=* <br /> Qrocrt <br /> Distance to sewer line l <br /> Domestic well on site - (Y7 n ) ft- <br /> If yes, location and distance - IV> ft.l D <br /> = e <br /> — o <br /> SAMPLING slatwd <br /> soc;icn <br /> Holding Temperature ';- _ 7"'91 Pack <br /> Method '` <br /> Screening Method <br /> Tracking Sheet - (y/ n <br /> -F-IL = n <br /> SPOILS ' <br /> Storage Method {� <br /> MATERIALS/DEVELOPMENT S <br /> Contamination Noted - (y/ 1�� �V T Casing type 1 <br /> Storage Location Blank ft, Screen fr <br /> Slot size s <br /> GROUTING Bags deement <br /> Buckets bentonite <br /> Depth to water U`P Bags sand gravel <br /> Mix Ratios <br /> Filter Pack type/size <br /> Installation Method \ ' Surge Block: - (y/(q) <br /> Quantity Installed Discussed with geo ogist:%o/ n) <br /> Type of method_ kJ �/ <br /> EH 29 29 <br />