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MONITORING WELL INSTALLATION REPORT <br /> Date:t C CONSTRUCTION <br /> Premise Address:It,dG"�> 1 lr z t_i►� r- Z.� � Total Ie nth <br /> Well No.: �j I f Screen Length (from)' <br /> Filter Pack (from)` (tO) <br /> Inspector:- C2G�C� Vv Bentonite (from) (to)' <br /> Grout (from) (). <br /> Permit No. Drilling rig type 5L'2y'.✓` 7✓1�- �(-= <br /> Auger O.D. I.D. <br /> Drilling Company:_ � � Completion - Stove pipe/christie box (circle one) <br /> I�ICJ1i1C�. <br /> Driller: V�� <br /> casing <br /> Consultant ��-���-� � �� � �L <br /> height <br /> Geologist 1 .' <br /> ABOVE-GROUND <br /> CO MPLET{O N C-HR ZTY-BOX <br /> SPECIAL PERMIT INFO COMPLETION <br /> Gnxmd Surfxa <br /> Distance to sewer line grout <br /> Domestic well on site - (y n <br /> If yes, location and distanceC �- ft. <br /> J- 5 <br /> SAMPLING _— <br /> o <br /> a to ttad = c <br /> Holding Temperature ax~aon <br /> Method <br /> _ "Val Pack <br /> Screening Method <br /> Tracking Sheet - (y/n) _ <br /> SPOILS <br /> Storage Method_ C-A --t-DI- MATERIALS/DEVELOPMENTContamination Noted - (y/n) - <br /> Storage Location - _ `— Casing type �+ <br /> Blank `_7.tiJ ft. Screen <br /> ft. <br /> GRODUING Slot size (')<C> <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios\C: -'-t�Ib ��� -��-�(�ti w Bags sand/gravel - c-?o <br /> �5,gc,, �G Filter Pack type/sizr <br /> Installation Method_��a,�,�VV k<— ' <br /> __ . __ --_.__ Block:_- ( -n-)-- <br /> ----.-Surge _ <br /> Quantity InstalledDiscussed with geologist. - (y n) <br /> EH 29 29 Type of method <br />