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MONITORING WELL,INSTALLATION REPORT <br /> '- ��•-r- -tea M <br /> Date: a Y. -+ A <br /> -" - CONSTRUCTION <br /> Premise Address: 11 11 � <br /> Total Depth C <br /> ' Screen Length (from) (to) <br /> ' Well No.: Filter Pack (from) (to) <br /> Bentonite (from) -g: (to) <br /> Inspector. -- <br /> Grout (from) <br /> (from) (to), _ <br /> Drilling rig type <br /> Permit No. Augei O.D.11 I.D. <br /> Completion''- Stove pipe/christie box (circle one) � <br /> Drilling Company: <br /> Driller: <br /> Cd31nCJ , <br /> height <br /> Consultant <br /> T <br /> Geologist <br /> j ABOVE-G19 IND CiiFiiSTY-80X <br /> COMPLETION r" <br /> SPECIAL PERMIT INFO. Ground Swian <br /> Distance to sewer line 4rw <br /> Domestic well on site - (y/n ) <br /> If yes, location and distance - <br /> •�y 1l. <br /> J. p <br /> SAMPLING R ii Yloroi <br /> - <br /> Holding Temperature_.�� .. <br /> Method <br /> Screening Method <br /> Tracking Sheet (y/n <br /> IE <br /> SPOILS <br /> Storage Method <br /> ,-MATERIALS/DEVELOPMENT <br />' Contamination Noted - (y/ n)' <br /> P <br /> Storage Location Casing type. <br /> Blank Il' ,; fL Screen ft. <br /> -;- SIOt size <br /> GROUTING / Bags cement l <br /> r Buckets bentonite <br /> Depth to water �.S 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 /> X ` - Type of method <br /> EH 29 29 <br /> i <br />