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MONITORING WELL INSTALLATION REPORT <br /> Date: dt'�o7��/�'S� CONSTRUCTION <br /> Premise Address: /6 y�,rf'�'��/.�so�l'�� Total Depth 1,V <br /> Screen Length (from) (to) <br /> Well No.: �1��'�`/.y' Filter Pack (from) 5 –(to) <br /> Bentonite (from) :Fe (to) <br /> Inspector: c �� �� Grout (from) j;;c (to) <br /> Drilling rig type .P7 �� <br /> Permit No. _f l'-c �s/ —I/YL�-JCs / Auger O.D. 4, I.D. <br /> / Completion 'Stove pipe clu�istie box (circle one) <br /> Drilling Company: ��.1-C '� <br /> Driller: sing <br /> height <br /> ConsultantVIA —qVT <br /> Geologist -- <br /> ABCVE-GRC(JND CNRIM43OX <br /> COWLErION COMPLETICN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line ', -� � a.F grout <br /> Domestic well on site - ( y/ n_) �r✓�, <br /> ' ft. <br /> If yes, location and distance - <br /> r <br /> SAMPLING •lot•o� <br /> soden '– <br /> Holding Temperature <br /> Method <br /> Screening Method r — <br /> Tracking Sheet - ( y/ n ) _ <br /> 2ft. I <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios $s, �c �' ' Filter Pack type/size <br /> Installation Method�'���,a �%��, ��r�fr'��f%-�r ,rp"41­t J� Surge Block: - ( y/ n ) <br /> Quantity Installed ­7; Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />