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MONITORING WELL INSTALLATION REPORT <br /> . / off ( - <br /> Date: _7A CONSTRUCTION <br /> Premise Address: `/ C•1- li(.3 Total Depth <br /> Screen Length (from)_ ( (to) <br /> Well No.:_�? Filter Pack (from) (to) / <br /> Inspector: �/w �- Bentonite (from) l (to) 1 <br /> Grout (from) /7 (to) <br /> Drilling rig type <br /> Permit No. �/Z xv 0 D 7-0/5� Auger O.D. ° ' I.D. <br /> Drilling Company: <br /> Completion - Stove pipe/christie box (circle one) <br /> ^an �i'1`.SCfi11� <br /> Driller: /ai2/ <br /> �(—� casing <br /> Gj height <br /> Consultant \ <br /> VTA <br /> Geologist &al) 4,- <br /> ABOVE-GROUND <br /> fOMPLETION Ca-IR15TY 80X <br /> SPECIAL PERMIT INFO. Ground Surface _ COMPLETION <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n ) <br /> If yes, location and distance - ft• <br /> ft. <br /> — m <br /> = m <br /> SAMPLING slotted <br /> m <br /> sacdon — <br /> Holding Temperature = <br /> Method vlyw 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 ;PV <br /> Blank ft. Screen <br /> Slot size <br /> GROUTING Bags cement 6 X <br /> Buckets bentonite <br /> Depth to wa r Bags sand/gravel <br /> Mix Ratios � X t3tFilter Pack type/size <br /> Installation Method AS t Surge Block: - (y/n ) <br /> Quantity Installed -t Discussed with geologist: - (y/ n ) <br /> EH 29 29 z �' �` 64i-S X 1 7� Type of method <br />