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MONITORING WELL INSTALLATION REPORT <br /> Date: A/� 0- /OxvIy CONSTRUCTION <br /> Premise Address:c;L4?V) `� *, /� (, Total Depth <br /> Screen Length (from) (to) <br /> Well No.: <br /> -5 ez?l—S S Pte` q Filter Pack (from) (to) <br /> InsPector: �r _ p Q Bentonite (from) (to) <br /> Ls�y� Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> / Completion - Stove pipe/christie box (circle one) <br /> Drilling Company:_ <br /> Driller: casing <br /> n- r T height <br /> Consul[antJ]�'f!t Cactt4 � <br /> Geologist A0 A A&M.t ('q l Cv�?��'7 r 0-1 <br /> ABOVE-GROUND <br /> COMPLETION CHRISiY-Box <br /> SPECIAL PERMIT INFO. COMPLETION <br /> Ground Surface <br /> Distance to sewer line p� <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - l n. <br /> —n. <br /> n. <br /> = m <br /> = m <br /> SAMPLING — o` <br /> $lo tied — c <br /> Holding Temperature y �L ion <br /> Method _ = pnvel pads <br /> Screening Method <br /> Tracking Sheet - (y/n ) . <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type�� <br /> Blank h. Screen $, <br /> GROUTING Slot size <br /> Bags cement <br /> i Buckets bentonite_ a , - <br /> Depth to water Bags sand/gravel <br /> Mix Ratios_/I,rof Cr Filter Pack type/siz 1;1-- <br /> Installation Method Surge Block: - (y/ n <br /> Quantity Installed 3 Discussed with geologist: - / n ) <br /> EH 29 29 <br /> Type of method lJ <br />