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MONITORING WELL INSTALLATION REPORT <br /> Date: l o�r y/6 'g– CONSTRUCTION <br /> Premise Address. t/tIO C/Aa f-a k) Total Depth_ I let <br /> Screen Length (from) 10 61 (to) <br /> Well No.: Filter Pack (from)/m$ (to) ( 9 <br /> Bentonite (from (to)—LnA,� <br /> Inspector._ [�,n coa Grout (from) : (to) /n f <br /> Permit No. <br /> 3 Drilling rig type <br /> Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: (2. ar�4 S�cr <br /> DrillerJ-�Y� c /`ti casing <br /> height <br /> Consultant t-- r e n. '4 + <br /> Geologist_ r>OL 1atiT � <br /> • ABOVE•GRCUND <br /> OGWLETION CYRSTY-Box <br /> SPECIAL PERMIT INFO. CO&L-tz CN <br /> Distance to sewer line Qra <br /> Domestic well on site.- / n) ft. <br /> If yes, location and ' ance - <br /> �5.n. <br /> ^~ O <br /> C <br /> SAMPLING = <br /> Aonad 3 = � <br /> socicn -Holding Temperature = ; <br /> Method = <br /> Screening Method ;� = <br /> Tracking Sheet - (y/ ri) <br /> I l`� n. = n. <br /> SPOILS A <br /> Storage Method /\A« 0 � MATERIALS/DEVEL.OPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location ay, 5ff4 Casing type Li ey C <br /> Blank I Icy fr. Screen I n K• <br /> Slot size wZCJ <br /> GROUTING Bags cement <br /> Buckets bentonite 1 F Ic 34 <br /> Depth to water N�(p Bags sand/gravel <br /> Mik Ratios � d Filter Pack type/size 2- 1 <br /> ,Installation Me� Surge Block: - (YID <br /> Quantity Installed Discussed with geologist: - (y/–n7b <br /> Type of method <br /> EH 29 29. . <br />