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MONITORING WELL INSTALLATION REPORT <br /> Date: 3 CONSTRUCTION <br /> r}�u7^E C <br /> Premise Address: ) /2 ap Z �U Total Depth / <br /> Screen Length (from) / (to) rJ <br /> Well No.: l� ya Filter pack (from) <br /> Inspector: �j(JQ�(�— Bentonite (from) $— (to) 3 <br /> V. Grout (from) 3 (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. A I II.D. <br /> Drilling Co <br /> � ��� Completion - Stove pipe/christie box (circle one) <br /> —m7p�^any:_ <br /> Driller:_ Fnel '�(—'� casing <br /> 4 height <br /> Consultant <br /> Geologist <br /> .' <br /> ABOVE-GROUND <br /> CC PLETION CNRJST'-80X <br /> SPECIAL PERMIT INFO. Ground x <br /> Sale COMPLETION <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n ) <br /> If yes, location and distance - _ ft. <br /> SAMPLING stottad ._ <br /> sacdon = <br /> Holding Temperature <br /> Method — gmyw Pack <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 A/(., <br /> Blank ?✓ ft. Screen <br /> Slot size <br /> GROUTING Bags cement _ 7 <br /> Buckets bentonite <br /> Depth to watar Bags sand/gravel <br /> Mix Ratios_( _ � Filter Pack type/size <br /> Installation Method FWE4 Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 ' � �7 a��� <br /> y� <br />