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C) <br /> MONTTORING WELL INSTALLATION REPORT <br /> Date: 1 Al I 0 7 CONSTRUCTION <br /> �s <br /> Total De <br /> Premise Address: � Depth. <br /> 1 Screen Length (from) (to) <br /> Well No.:_f1�1 w - -- Filter Pack (from) (to) <br /> Bentonite (from) - _ (to) r <br /> Inspector.-� � Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. Y.D. <br /> �+� Completion - Stove pipe/dzristie box (circle one) <br /> Drilling Company: 155c� <br /> casing <br /> Driller• yheight <br /> Consultant <br /> Geologist ABUYE-GACAJND ��M_Box <br /> t�l�fP[.ETION 1 C4I+;Pt.��TICN <br /> 4r <br /> SPECIAL PERMIT INFO. Grourd S�'�`` _ <br /> Distance to sewer line - <br /> Domestic well on site - (y/ n) tt <br /> if yes, location and distance - ft. <br /> r — <br /> 4 <br /> y; O <br /> ' C <br /> SAMPLING <br /> sacicn <br /> Holding Tqnperature 1 �� — V1 'a;Pack <br /> Method 1 �t <br /> Screening Method ff <br /> Tracking Sheet f©/n ) _ <br /> SPOILS <br /> Storage Method r MATERIALS EVELOPMENT <br /> Contamination Noted i (y/n) Casing type "RVCJ Sc,Q (4v <br /> Storage Location ft. <br /> _ Blank Et. Screen <br /> Slot size <br /> GROUTING ,_:Bags cement --�— <br /> 'Buckets bentonite,/Yt IT <br /> Depth to water 'bl Bags sand/gravel <br /> Mix Ratios n' ' Filter Pack type/size <br /> installation Method Surge Block: - (y/Al <br /> Quantity Installed 7 ' Discussed with geo gist: - { 'r/n) <br /> Type:of method �JJ <br /> EH'29,29 _ <br />