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MONITORING WELL INSTALLATION REPT <br /> Date: �� 0� CONSTRUC 7ON <br /> Premise Address:JJ 7s u + Total Depth <br /> (� ' Screen Length (from) (CO) <br /> Well No.: .Y _. r Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. Grout (from) (to)- <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> Driller. casing <br /> S ex- height <br /> Consttlt�Tt <br /> Geologist <br /> 7, AAVI i SAO-krZCO!E-GA o C ergs-aox ' <br /> CGMPLE f10N <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line 4rart <br /> Domestic well on site - (y/n} ft. <br /> If yes, location and distance - <br /> �• ft. <br /> V�' O <br /> wc <br /> SAMPLING — <br /> :lar.4.i Y. � <br /> ��� on '> --- <br /> Holding Temperature <br /> Method lb-43 Pac` <br /> Screening Method 14 TC-#"r <br /> Tracking Sheet - /n) _ <br /> M <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - {y/n} <br /> Storage Location Casing type <br /> /mow `l ' y�j/� T, !). Blank ft Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water t7 Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - {y/ n } <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />