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MONITORING WELL INSTALLATION REPORT <br /> 10. 11 <br /> ";I % ^ CONSTRUCTION <br /> lMW �t0i1 <br /> Date: r_ t- �(� <br /> Premise Address: � t 5 b�1li,,tt- Total Depth G <br /> Screen Length (from) 6, (to) <br /> Well No.: / h1 `AJ A w/d MA/'? Filter Pack (from)_ (to)C c <br /> / Bentonite (from) (to) <br /> Inspector: / C- Grout (from) <br /> Drilling rig tyke <br /> Permit No. Auger O.D. t I.D. <br /> rr Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: , 071� <br /> `i <br /> Driller: casing <br /> height <br /> Consultant (2z" '��VJc- <br /> Geologist LIS <br /> ABOVE-GROUND CHRIS7Y-BOX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface T —'-- <br /> Distance to sewer line h1,l�I grout <br /> Domestic well on site - (y/ n ) ♦ S 1 - '. <br /> If yes, location and distance - S-q ft. <br /> m <br /> a <br /> _ m <br /> C <br /> -- O <br /> SAMPLING pJ� dotted <br /> Q� agcdon <br /> Holding Temperature gravel pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) _ <br /> eft. '� — ft• <br /> SPOILS T <br /> Storage Method MATERIALS/DEVELOPMENT - IIW <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank S Y, ft. Screen <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite d <br /> Depth to water ` I p t S� Bags sand gravel 4-Q <br /> Mix Ratios A,__A•C rff�� Filter Pack type/size <br /> Installation Method _ Surge Block: - ( y/ n ) <br /> Quantity Installed j2�/� Discussed with geologist: - (�yJ/ n ) <br /> Type of method <br /> EH 29 29 <br />