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MONITORING WELL INSTALLATION REPORT <br /> Date:__ CONSTRUCTION <br /> l Pk Sj ucA-,P_ <br /> Premise Address:_ 5 (0-0 Total Depth (05— <br /> 'A <br /> 0S Well No.: 1 Screen Length (from) ST (to) �, r <br /> i Filtar Dark (fry��) S" (to)— � <br /> \' Bentonite (from) S-7) (to) S <br /> Inspector: _I p kd Grout (from) o . -; 15:(to) o <br /> 59 71 �� Drilling rig type u-- <br /> 60 <br /> Permit No. Auger O.D.._�j, Z S I.D. 8• b <br /> , 11 <br /> Drilling Company: °o Completion - Stove pipe/christie box (circle one) <br /> W � �,-, 0 ref <br /> Driller:_ DGV 2 ��v.S �yy1e casing <br /> I height <br /> Consultant Pr 6 (% * ' <br /> Geologist_ <br /> ABOVE-GROUND <br /> CCWFLETZN \ CHRIS7Y 80X <br /> SPECIAL PERMIT INFO. LCGMPLFTIQbN:�- <br /> Grour�Suriaca <br /> Distance to sewer line --7p; <br /> Domestic well on site - (y A0 <br /> If yes, location and distance - ft. <br /> 5S ft �3 ft• <br /> = m <br /> q <br /> = m <br /> SAMPLING — i? <br /> slotted — c <br /> Holding Temperature N — <br /> Method — 9nY'E�Pack <br /> Screening Method <br /> Tracking Sheet - (y/n) f/ <br /> SPOILS <br /> Storage Method co MATERIALS/DEVELOPMENT <br /> Contamination Note�- (y/nh) <br /> Storage Location Casing type SL H D U L <br /> Blank 5-5-- ft. Screen _�Z D ft. <br /> Slot size Q. b m `/ <br /> GROUTING Bags cement_ /A <br /> Buckets bentonite 1 <br /> Depth to water "3 Bags sand/gravel 2ya <br /> Mix Ratios (D Sct �ahr nor �l`f S 'r,� Filter Pack type/size -4V-t� <br /> Installation MethodSurge Block: - (®/n ) <br /> Quantity Installed Discussed with geologist: - (©/ n ) <br /> Type of method <br /> EH 29 29 <br />