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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: $fWr Total Depth <br /> Screen Length (from) 6'3. 0 (to) 3,U <br /> Well No.: W '7 Filter Pack (from) (03,0 (to) <br /> Bentonite (from) 40. Z (to) <br /> Inspector: �• �J �L � Grout (from) (to) $ <br /> n n Drilling rig typeC/ti!f ,SO <br /> Permit No. Y �7 S Auger O.D. f�/O. 3 <br /> Consultant <br /> ' 1 '4?3�/ Completio - Stove pipe ' tie box (circle one) <br /> Geologist IY�I /�5�LC. ' I-*-rfLL wryuc 17S' stld*•up <br /> A T <br /> T <br /> SPECIAL PERMIT INFO. ABOVEGROUND <br /> ! COMPLETION CHRISTY-aOX <br /> Distance to sewer line COMPLETION <br /> Domestic well on site - ( y/O t orSuA°°s <br /> If yes, location and distance - <br /> 0*out <br /> ft. <br /> n. <br /> N. <br /> O <br /> SAMPLING e <br /> Holding Temperature $Obt. Spflrpt tsS 7W4J slotted <br /> Method &ac:lo" x <br /> Screening Method Inv Pi = grawl pad* <br /> Tracking Sheet - (y/ n) r <br /> .Y <br /> = n. <br /> SPOILS <br /> Storage Method L ( MATERIALS/DEVELOPMENT <br /> Contamination Notes - (y/G) �,�+ 44 AIC. <br /> Storage Location 01U Sl W-! yz ruw ) /d'�iYrizx Casing type <br /> Blank a3 ft. Screen ZC7 ft. <br /> Slot size ('•0 ZU <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> //GG / Bags sand/gravel <br /> Depth to water `l7• Filter Pack type/ ize 2 <br /> 1 <br /> Mix Ratios Cl gAtLL A44 Surge Block: - nn) <br /> Installation Method 71LuiuM!d3 Discussed with geologist: n ) <br /> Quantity Installed Type of method <br />