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MONITORING WELL INSTALLATION REPORT <br /> Date: k,I (� I C'n CONSTRUCTION / <br /> Premise Address: t 1(7'o A) . �( Total Depth �K <br /> Screen Length (from) ( (to) G u <br /> Well No.: M Inl '(� Filter Pack (from) U 7 ' (to)��j <br /> Bentonite (from) (to) i <br /> Inspector Grout (from) 8 (to) 3�t <br /> Drilling rig type <br /> Permit No. SCJ Z 2 Z Auger O.D. I.D. <br /> Completion - Stove pipe/christle box (circle one) <br /> Drilling Company: �A)��.-( F�•;�VI.1ar�� <br /> }'� J <br /> Driller: t RTnA casing <br /> c ,, _ height <br /> Consultant d L-t'S�. � � <br /> —QV <br /> Geologist hOlMn, ix <br /> ABOVE-GACOND G�itSTY30X <br /> 00kVLFr1CN COMPLRICN <br /> SPECIAL PERMIT INFO. Gmund Su tars <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - ( y/ n ) 3 It <br /> If yes, location and distance - ft <br /> SAMPLING slotted <br /> sac'cn — <br /> Holding Temperature Cnn i (h yTaysi Pack <br /> Method C (5'1fn,z ,3.QCa,tta <br /> Screening Method rt D <br /> Tracking Sheet - / n ) <br /> SPOILS <br /> Storage Method ( MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y n <br /> Storage Location Casing type <br /> Blank_-a-q ft. Screen----2 <br /> Slot size O z C> <br /> GROUTING Bags cement <br /> Buckets bentonite CT <br /> Depth to water j Bags sand/gravel <br /> Mix Ratios S&rj4p vop SSC <br /> t icti Filter Pack type/size I Z --)-CAVb l <br /> Installation Method I 12,A A Surge Block: - ( y/ n� <br /> Quantity Installed /-1j O e Discussed with geologist: • (y/o <br /> Type of method <br /> EH 29 29 <br />