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MONITORING WELL INSTALLATION REPORT <br /> Date: 17 –I 3 CONSTRUCTION <br /> Premise Address: 11 _01 'f•)fAj P XWy Total Depth I�� <br /> Well No.: ��' &I Filter <br /> Length (from)' /v (to) /lam <br /> Filter Pack (from) q (to) /o <br /> Bentonite' (from) 3 (to)�_ <br /> Inspector: Grout (from) '(to). <br /> skocy,G 3q Dulling rig type Q6wro TE ALJMsz <br /> Permit No. Auger O.D. 2 7 I.D. <br /> Drilling Company:_VYf. y U eP I 7ve N Completion- Stove pipe/chnstie box (circle one) <br /> Driller: <br /> casing <br /> height <br /> Consultant STAwrce <br /> Geologist ,4ccirAfP_J1gVW5 4W77-1 _ <br /> ABOVE-GROUND <br /> COMPLETION OHAI577-80X - <br /> COMPLEION <br /> SPECIAL PERMIT INFO. Ground gLidw <br /> Distance to sewer line grout 60e,+9ca�✓1 <br /> Domestic well on site - (y/ ) <br /> If yes, location and distance - ft• <br /> - ft. <br /> ft. _ <br /> SAMPLING <br /> dotted <br /> Holding Temperature <br /> Method S"' = gnm pads <br /> Screening Method Z — <br /> Tracking Sheet - (y/n) .. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Note - -Cy/n) <br /> Storage Location Casing type pve <br /> Blank to' ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite A/i4 <br /> Depth to water /L. Bags sand/gravel �6Ar <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block:__(.y A )_ _ <br /> Quantity Installed Discussed with geologist: - (y/ f�i j <br /> EH 29 29 Type of method <br />