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MONITORING WELL INSTALLATION REPORT <br /> Date:—c /o D� CONSTRUCTION <br /> / D <br /> Premise Address: Sy9� �` S Total Depth <br /> /J� Screen Length (from) (to) Z <br /> Well No.:—A"� J Filter Pack- (from) (to) 2 y <br /> Bentonite (from) - (to) <br /> Inspector: �C Grout (from) 0, (to) 3 ' <br /> c / Drilling rig type <br /> Permit No. J 51L9 37 ile Auger O.D. I.D. <br /> Completion- Stove pipe/christie box (circle one) <br /> Drilling Company: (/�����''� <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist /O�Lt ✓���/ l <br /> ABOVE-GROUND <br /> COM?LETJON CNR1SrY-80X <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surfac* <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - , ft. <br /> . ft. <br /> ft. <br /> = m <br /> SAMPLING — <br /> slottQd � — � <br /> aac;ion "- <br /> Holding Temperature = . <br /> Method ' _ gm"�Pack <br /> Screening Method -" <br /> Tracking Sheet - (y/n) "- <br /> it. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) ;/ <br /> Storage Location Casing type f U C -7 <br /> Blank D- _5;� ft. Screen 20 ft. <br /> Slot size aZD <br /> GROUTING Bags cement_ T'-f / <br /> Buckets bentonite_ of / <br /> Depth to water Bags sand/gravel *%54-4 G 6 sys <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> EH 29 29 Type of method <br /> rn <br /> l.� <br />