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MONITORING WELL INSTALLATION REPORT <br /> Date: I2 �2Irl Oct CONSTRUCTION <br /> Premise Address: 113 -,i 5 • ,S f oc k. Total Depth 30 _ <br /> Screen Length (from) t O (to)3 0 � <br /> Well No.: VVX fnl — I Filter Pack (from) (to)_ 3d <br /> Bentonite (from) g (to) CI <br /> Inspector: 0 tnnnr a Grout (from) or (to) it <br /> Drilling rig type <br /> Permit No. C D 3 Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: 125 <br /> Driller: casing <br /> height <br /> Consultantt% —VV' <br /> G"I";Iot 666CO tAA.0-1 V <br /> ASOVE•GROUND CNRSTY-BOX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Sauce <br /> wer line grout <br /> Distance to se <br /> Domestic well on ' e • (y/n ) 1 4 ft- <br /> If yes, locatio d distance - c ft <br /> S = m <br /> O <br /> 9 <br /> C <br /> O <br /> SAMPLING tlonad <br /> taction <br /> Holding Temperature = grave'Pads <br /> Method core%, <br /> Screening Method s^ <br /> Tracking Sheet - ( y/ n) <br /> 0 <br /> SPOILS <br /> Storage Method SS^�+f �— MATERIALS/DEVELOPMENT <br /> Contamination Noted -a n ) <br /> Storage Location cn. s�6 Casing type Z PVC <br /> Blank_(0 ft. Screen zo h <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - ( y G) <br /> Type of method <br /> EH 29 29 <br />