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MONITORING WELL INSTALLATION REPORT <br /> Date: �l ( 61 CONSTRUCTION <br /> Premise Address-ZLO� W. Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: 49! .n� Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: 9SX' Completion - Stove pipe/christie box (circle one) <br /> Driller: casing <br /> / height <br /> c <br /> Consultantj�_� ��/ �, <br /> -QV-f <br /> Geologist > , �-�^"���r� <br /> ABOVE-GROUND <br /> 0OMPLEf10N C4{RIM43OX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Suriacs <br /> Distance to sewer line P7, grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft <br /> . ft. <br /> ID <br /> ft. <br /> — m <br /> - C <br /> SAMPLING = <br /> sbttad — C <br /> wt9on — � <br /> Holding Temperature YOC, <br /> Method gravel 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 <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <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 />