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MONITORING WELL INSTALLATION REPORT <br /> Date:_ s_ /rte 0 <br /> CONSTRUCTION <br /> Premise Address: Li A5 L4 of ` <br /> Total Depth <br /> Well No.:--4& U3 S n p (from). (to) <br /> -� '� Screen Length (from)Filter Pack (from) _(to) _ <br /> Inspector. (� �• Bentonite (from) 13 (to) r- <br /> Grout (from) $ (to) _ <br /> Permit No. Drilling rig type <br /> Auger O.D. <br /> Drilling Company: Completion - Stove pipe/cli istie box (circle(cir�e) <br /> Driller. 71 <br /> casing <br /> Consultant � r height <br /> Geologist �,(�Qt t —W-T <br /> -,inn UPW _ <br /> r —�-- AECVE-GACUND <br /> SPECIAL PERMIT INFO. COWLEr CN C4�R:'-aox <br /> CCMPL_R1CN <br /> Ground Srzfacs <br /> Distance to sewer line <br /> Domestic well on site - (y/n grout <br /> Ifyes, location and dista <br /> tt. ft. <br /> _ - a <br /> _ — m <br /> SAMPLING = c <br /> �fonnd i — c <br /> Holding Temperature soc'icn '<: _ <br /> Method = <br /> Screen inglvte :y = pavalyacs: <br /> Trackin <br /> '., _ <br /> SPOILS "-� tt' <br /> Storage Method <br /> Contamination Noted - (y n 1 MATERIALS/DEVELOPMENT <br /> OPMENr <br /> Storage Location <br /> Blank Casing type 2 "Ey� <br /> Screen`—h <br /> GR��.G Slot size O <br /> Bags cement <br /> Depth to water Buckers bentonite <br /> Mix Ratios_ z F, u N Bags sand/gmvcl <br /> Installation MethodeA Filter Pack type/size <br /> Quantity Installed <br /> A/L^' Surge Block: - (y/11 <br /> Discussed with geo 1)st: - (y) <br /> EH 29 29 Type of merhod <br />