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MONITORING WELL INSTALLATION REPOR� <br /> Date: Il/I l7 I D� II CONSTRUCTION <br /> Total Depth L' <br /> Premise Address:p <br /> g �, w ( �L I <br /> Screen Length (from)—(to)— <br /> Well <br /> from) (to)Well No.: �'- "� ' wr�Q� Filter Pack (from) (to) <br /> I �� Bentonite (from) (to) <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: <br /> Driller: 4�� casing <br /> height <br /> —WVTConsultant �T <br /> Geologist - ABOVE-GRC O <br /> COMPL`�TfON C>^ :STY3ClX <br /> COMPLEMN <br /> SPECIAL PERMIT INFO. rd Sutxr —� <br /> Distance to sewer line grout <br /> I�" (,M"I� , <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - tt. <br /> - = o <br /> alarad � <br /> SAMPLING socicn <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y <br /> SPOILS <br /> Storage MethodMATERIALS/DEVELOPMENT <br /> Contamination Noted • (y/ n) Casing type � p �n n <br /> Storage Location Blank fcY Screen rP R <br /> Slot size <br /> GG Bags cement <br /> ROITIIN -- <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Rados Surge Block: - (y/11) <br /> 4pstalladon Method Discussed vrith geologist: - (y/ n) <br /> Quantity Installed Type of mcdlod <br /> EH 29 29' <br />