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MONITORING WELL INSTALLATION REPOn f <br /> Date: 5 CONSTRUCTION <br /> Premise Address: 22 ( N' �'V Total Depth /��• <br /> /�2 Screen Length (from) (to) l ' <br /> Well No.: 'w Filter Pack (from) (to) <br /> Bentonite (from) (to) �3Z <br /> Inspector: Grout (from) 2 (to) o <br /> (� Drilling rig type <br /> Permit No. 10� Auger O.D. I.D. <br /> Completion - Stove pipe/ stile ox ircle one) <br /> Drilling Company: <br /> Driller: casing <br /> n G G height <br /> Consultant (�, <br /> Geologist � G7,1 T <br /> ABOVE-GROUND <br /> CO WP LETO N 4CHRZTY-BOX <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line ? grout <br /> Domestic well on site �n ) <br /> If yes, location and distance - <br /> J3R,Sn. <br /> r <br /> C <br /> SAMPLING ado I = c <br /> Holding Temperature <br /> Method —� _ �1 <br /> ack <br /> Screening Method <br /> C.; <br /> Tracking Sheet - ( y AZ51 ,ft —ft <br /> SPOILS <br /> Storage Method v /� f MATERIALS/PEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type J <br /> Blank 131?'. ft. Screen ft <br /> Slot size O zd <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size 3 <br /> Installation Meth&d Surge Block: - (y/ n <br /> Quantity Installed (s S Gam Discussed with geologist: - (y <br /> Type of method <br /> EH 29 29 <br />