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MONITORING WELL INSTALLATION REPOni <br /> �yD <br /> UC <br /> Dae:/ 3� /Z / CONSTRUCTION <br /> Premise Address : Total Depth IQ3 <br /> 6n /,�,�/ �( rA/� Screen Length (from) b (to) <br /> Well No. : 12ivv A�//W Qv Filter Pack (from) / (to) <br /> Bentonite (from) (to) 7 <br /> _ <br /> Inspector: Grout (from) (to) O <br /> Drilling rig type <br /> Permit No. �/l l0a Auger O.D. S•5' Ce 9 VAIJLLD,�� <br /> ` • - _ � _ Completion - St ve pipe christie box (circle one) <br /> Drilling Company: <br /> Driller:�d�/ ' �Gf/ll� ��� casing <br /> / height <br /> Consultant G4dus <br /> Geologist f <br /> ABOVE-GROUND CtiAISiY BOX <br /> COMPLETION la'l2 DAAPLETION <br /> SPECIAL PERMIT INFO. r � <br /> `_ �, �• p A dI� <br /> Distance to sewer line G" "I r /6 r Ce yyrcut <br /> Domestic well on site - ( y / n ) 8S <br /> If yes, location and distance - <br /> SAMPLING slanad = <br /> secSon �> <br /> Holding Temperatures Pack <br /> Method <br /> Screening Method_ <br /> Tracking Sheet - ( y / n ), <br /> IDD ft. ». <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMRNT <br /> Contamination Noted - ( y '�/�✓ 11 n U ® n <br /> Storage Location Casing type ,— T �Cn <br /> Blank ft. Screen <br /> Slot size • ®loly, <br /> GROUTING Bags cement =41.0 <br /> Buckets bentonite _ <br /> Depth to water Bags sand/gravel <br /> Mix Ratios a 7.0Z2 t = I Filter Pack type/size:: z _ <br /> Installation Method wt Surge Block: . ( y / n ) <br /> Quantity installed ZS? */- /50 Discussed with geologist: - ( y / n ) <br /> Type of method <br /> EH 29 29 <br /> 0 , <br /> Y5 <br /> l2� y`o �r �� , <br /> { 9)J, <br />