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MUVNITORING WELL INSTALLATION REPOR7,..00, <br /> Date: 1q3 CONSTRUCTION <br /> �g 6 �� s 7�'1 C� <br /> Premise Address: Q,C '` Total Depth 103 <br /> Screen Length (from) /03 (to) X3 <br /> Well No.: Filter Pack (from) /63 (to) 8 / <br /> Bentonite (from) '3 (to) <br /> Inspector. Grout (from) (to) <br /> Drilling rig type 8 <br /> Permit No. — Auger O.D. -3 U I.D. <br /> �L–=" Completion- Stove pipe/ s e bo (circle one) <br /> Drilling Company: <br /> Driller. casing <br /> rrnn •,�� T height <br /> Consultant uLyy <br /> Geologist 171 —qv <br /> AEZ0 -GACUND CNRMIry-80X <br /> COAFL.ETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Sutfacs <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - M <br /> O <br /> SAMPLING <br /> _ 3 <br /> aaCScn ?f- <br /> Holding Temperature <br /> _COgmvw <br /> � = <br /> Method _ Pack <br /> w� <br /> ^. <br /> Screening Method <br /> Tracking Sheet - (y/ n) %A, <br /> v� <br /> ft. — 03 tL <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ j– C <br /> Storage Location Blahtype__ <br /> 'R 3f Screen <br /> Slot size 2 <br /> GROUTING Bags cement �- <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel ` 5 <br /> Mix Ratios Filter Pack type/size R M C 3 <br /> Installation Method Surge Block: - n ) <br /> Quantity Installed Discussed with ogist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br /> z. <br /> �Y 7- J AW z <br />