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MONITORING WELL INSTALLATION REPORT <br /> Date: Or CONSTRUCTION <br /> Premise Address: 3931 /1'/ �� G� Total Depth />2g?- <br /> Screen Length (from) (to) <br /> Well No.: 1�TyJ ���"� �Zg Filter Pack (from) (to) <br /> Bentonite (from) (ro) <br /> Inspector. �;1/G e1 Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/chrisrie box (circle one) <br /> Drilling Company: <br /> rva�k Zeyr�ava)o. casing <br /> Driller: �F he_ght <br /> Consultant _i� A 7 <br /> Geologist �✓fil/<�/ <br /> / tieove�acuND crwsrr-aox <br /> �yrWr�/ OOWLETCN CCM EMCN <br /> SPECIAL PERMIT INFO �6 �r Grourd Suia" + <br /> pra.2 <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) It. <br /> If yes, location and distance - n <br /> h. <br /> — - m <br /> - = o <br /> = c <br /> slonvd ` <br /> SAMPLING socion <br /> Holding Temperature <br /> Method <br /> Screenin;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 ft. Screen."-fr• <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water q0 Bags sand/gravel <br /> Mix Ratios 5V I If d Filter Pack type/size <br /> Installation Method fi ° Surge Block: - (y/ n ) <br /> Quantity Installed -7u-fit / If Discussed vAth geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />