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MONITORING WELL INSTALLATION REPORT <br /> Date : ' � CONSTRUCTION <br /> -.. as f /hW els <br /> Premise Address : S/ ? .fG y � y Jtr Total Depth. <br /> Screen Length (from) 0S (to) / 0 <br /> Well No. : /Ylw Fi d iwJ ! Filter Pack (from) / D (to) R <br /> Bentonite (from) 4 (to) —FeI <br /> Grout <br /> Inspector: C'n� (from) A (to) <br /> Drilling rig type <br /> Auger O.D. k 11I .D. <br /> Permit No . Completion • Stove pipe/ tsue bot (circle one) <br /> Drilling Company: A )&d /K) k <br /> Q n casing <br /> Driller: /17 / �m /\ 0. /rkk° v � Y�h height <br /> Consultant AgeG F <br /> Geologist i �� L rf>`�2. - ABOVE•GRCUND VCN <br /> CONPL.GTION <br /> SPECIAL PERMIT INFO, Cvwnd Sucix+ <br /> grout <br /> Distance to sewer line < ZO <br /> Domestic well on site - ( y / (9 Ile - -- tt" <br /> If yes , location and distance ft- <br /> �• O <br /> _ _ a <br /> c <br /> SAMPLING eV , S STSG^ 9 tlored <br /> tacicn <br /> Holding Temperature � ca✓ _ �ravd Wdc <br /> Method A.10 Orb 92D <br /> Screening Method <br /> Tracking Sheet - ( y / n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVEI ,OPMENT <br /> Contamination Noted • ( y /Q9 �� , , n <br /> Storage Location / �/ 7 N�Zt Casing type <br /> Blank /S h. Screen fr• <br /> Slot size O2� <br /> GROUTING Bags cement <br /> Buckets bentonite < <br /> Depth to water. <br /> Bagssand/gravel <br /> Mix Ratios _ Filter Pack type/size <br /> Installation Method YOrrN/t - Surge Block: - C? / tt ) <br /> Quantity Installed Discussed with geologist: - ( ®/ n ) <br /> Type of methodn,Z <br /> EH 29 29 <br />