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MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> ACONSTRUCTION <br /> Sf .Ifatfy, �_ <br /> Total Depth--,2 <br /> Premise Address: 3 Screen Length (to)_ <br /> Filter Pack (from) 43� // <br /> Well No.: M - . Bentonite (from) 5g3 '1L�(to) <br /> '` r7Gf . Grout (from) 4 ' ie " (to) Sur �« <br /> Inspector. _�L Drilling rig We_,G M• E �s <br /> dQ 7 3 Auger O.D. <br /> ID. ! 25 " <br /> Permit No.— —_ <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company <br /> casing <br /> �� <br /> Driller: <br /> 1'!7e. he <br /> / $Z ight <br /> Consultant <br /> t�!����� <br /> cUiRZT r-Box <br /> Geologist Y m 1 l e Y �BovF-��eucrD <br /> cONVLEMN me <br /> C;=rd sviaca <br /> SPECIAL PERMIT INFO. gfo t <br /> k4 <br /> 1 ' !/ <br /> Distance to sewer line <br /> Domestic well on site - (y A-'D <br /> If yes, location and distance <br /> •:r:. <br /> C <br /> SAMPLING sQcicn <br /> .� <br /> Holding Temperature <br /> Method �'ee 1 .7 — <br /> Screening Method— — • <br /> Tracking Sheet - (Y/dn, <br /> SPOItS NT <br /> MATEDepOEM <br /> Storage Method �, H 1 _;! D <br /> Contamination Noted - .� Casing type <br /> Blank A L fr' Screen <br /> Storage Location �o <br /> Slot size <br /> Bags cement + s <br /> GROUTING S i n1 .CIA l r' Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water 3 d f.�f�y Filter Pack type/size <br /> Mix Ratios Surge Block: - (Y�) <br /> Installation IM <br /> r �yEs�Discussed with geologist: - n) <br /> Quantiryinstalled Type of method <br /> EH 29 29 <br />