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MONITORING WELL INSTALLATION REPOri,f <br /> Date: X12 Z•�j, Z� <- CONSTRUCTION <br /> Premise Address: (� 1�1 - M �� Total Depth 3 G <br /> c Screen Length (from) `35' (to) 2_,z, <br /> Well No.: O Filter Pack (from) ?J!o (to)— <br /> Bentonite (from) (g (to) NO <br /> Inspector: Grout (from) ((o (to) o <br /> c' Drilling rig type 1 tfb <br /> Permit No. �c�� Auger O.D. g' I.D. _ <br /> 100Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: �(�J <br /> Driller: casing <br /> �� �� height <br /> Consultant _ - - <br /> T7 <br /> Geologist �� - -�0 •- <br /> IN <br /> ABOVE-GROUND <br /> COMPL.E ;CN COMPLE 1ON <br /> OMPLETlON <br /> SPECIAL PERMIT INFO. Ground Suriaca <br /> Distance to sewer line <br /> S O grout <br /> Domestic well on site - ( y <br /> If yes, location and distance - <br /> = m <br /> — m <br /> SAMPLING slotted = ' <br /> 4n G soon <br /> Holding TemperatureVIVW Pack <br /> I <br /> Method_ <br /> Screening Method -_ <br /> Tracking Sheet �n ) <br /> 35 _ � <br /> SPOILS 3 to <br /> Storage Method 4'~ MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y,40 <br /> Storage Location Casing type 1' <br /> Blank 2-,D ft. Screen ► S ft• <br /> -r <br /> Slot size •01-0 <br /> GROUTING Bags cement $ - !o - <br /> Buckets bentonite 1/9 / <br /> Depth to water Bags sand/gravel (o <br /> Mix Ratios EFOaft f Filter Pack type/size <br /> Installation Method Surge Block: - ( n <br /> Quantity Installed S Discussed with geo ogist: <br /> Type of method <br /> EH 29 29 <br /> 5 X �, a <br />