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MONITORING WELL INSTALLATION REPORT <br /> Date: f/UI � / ,— CONSTRUCTION <br /> Premise Address: � yf///��/f (U��"/ Total DepthO <br /> Q Screen Length (from) (to) <br /> Well No.: ` / Filter Pack_ (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: __/1,11614 1 Grout (from) D (to)� D <br /> Drilling rig type <br /> Permit No. Auger O.D. '3/' 1_I.D. <br /> Drilling Company: Completion- Stove pipe/christie box (circle one) <br /> �v/'S <br /> Driller: S)(? &155 r5-71 casing <br /> height <br /> Consultant <br /> -2-- <br /> //,� T <br /> Geologist J/�'✓d !/"`( W T <br /> ABOVEGROUND CNAISTY BOX <br /> OOMPLEfION <br /> COMPLE ON <br /> SPECIAL PERMIT INFO. Ground Surfa�w <br /> Distance to sewer lineut <br /> grout <br /> Domestic well on site- (y/n) 1 n <br /> If yes, location and distance - <br /> n. <br /> tt. <br /> SAMPLING <br /> -Aa <br /> ZS � bttQd M _ 8 <br /> d 20 CF 3p�� Re s dor secdon wE C . <br /> Holding Temperature _ so 3s - odor <br /> Method = yv' s.6* <br /> Screening Method — <br /> Tracking Sheet - (y/n) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen fc. <br /> Slot size <br /> GROUTING Bags cement '540ct 'e-') v c5 /cv ftA <br /> Buckets bentonite <br /> Depth to water 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 />