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MONITORING WELL INSTALLATION REPORP <br /> Date:�I2 I D3 /� CONSTRUCTION <br /> Premise Address: 2�'loo / Imo`+ Total De th <br /> l.(nr-�S�-.�- _ P <br /> Screen Length (from)—(10)— <br /> Well <br /> from) (to)Well No.: Filter Pack (from) (to) <br /> y Q Bentonite (from) (to) <br /> Inspector•. Grout (from)—(to)— <br /> .Drilling <br /> from) (to).Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> 9 •' _ \ Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling Company: �'O� <br /> Driller: casing <br /> rr height <br /> Consultant "� � r <br /> Geologist JSgOVEGRCUND <br /> CONFLETCN C0&1Pt=nCN <br /> COt,4PLETICN <br /> SPECIAL PERMIT INFO. Ground S '� <br /> s9, <br /> Distance to sewer line J ol.I-I SAH . grout <br /> Domestic well on site - (y/ n) Ln 041"A <br /> If yes, location and distance - / h. <br /> P <br /> - C <br /> O <br /> SAMPLING tlorai <br /> suc'cn — <br /> Holding Temperature al F'4k <br /> Method <br /> Screening Method = <br /> Tracking Sheet - (y/ n) <br /> SPOILS L <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) `11�'f� rS� <br /> Storage Location Casing type 7 <br /> g Blank fc. Screen_-----------ft. <br /> Slot size 0. 0 <br /> GROUTING Bags cement <br /> Buckets bentonite -- <br /> Depth to water Bags sand/gravel -z 1'2,- <br /> Mix Ratios Filter Pack type/ ' e i-z- <br /> Installation Method Surge Block: - n ) <br /> Quantity Installed Discussed with cologist: - 601 n ) <br /> Type of method <br /> EH 29 29 <br />