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MONITORING WELL INSTALLATION REPOR <br /> Date: O-Z> CONSTRUCTION <br /> Premise Address: 3d0 L", Total Depth r7 <br /> Screen Length (from) rvr (to) 3 of <br /> Well No.: ���e ��` 114 h ) Filter Pack (from) (to) <br /> Bentonite (from) L (to) G, <br /> Inspector. Grout (from) to (to) <br /> SwkJ Drilling rig type <br /> Permit No. Auger O.D. /y I.D. <br /> ho K�­�7 Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: y'`� ZS- .e <br /> 3 v' <br /> Driller: casing <br /> height <br /> Consultant <br /> GeologistABOVE-GROUND CH STY-BOX <br /> `I ofc0kFLETCN Con PLEMCN <br /> MI <br /> SPECIAL PERT INFO. Q`t GQ C�wnd S4xa <br /> Y r9 <br /> Distance to sewer line wbs/ �out <br /> 1 <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - h. <br /> 1� A. _ <br /> SAMPLING <br /> soden <br /> Holding Temperature _ " <br /> Method F <br /> Screening Method ' _ <br /> Tracking Sheet - / n ) <br /> ft. — n <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ t." /JCC y r� <br /> Storage Location Casing type, T , <br /> Blank G ft. Screen <br /> Slot size <br /> GROUTING f Sy ' Bags cement <br /> Buckets bentonite <br /> Depth to water s,,C, ! " Bags sand/gravel G2 <br /> Mix Ratios Filter Pack type/size / S <br /> Installation Method Surge Block: - (9/ n ) <br /> Quantity Installed Discussed with geologist: - fy� n ) <br /> Type of method— / p/4 <br /> EH 29 29 <br />