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MONITORING WELL INSTALLATION REPOi�P <br /> Dater f, CONSTRUCTION <br /> Premise Address: Oh 1SQ4 sGCA�'/ /`" Total Depth 40 <br /> w/ <br /> Wel] No.: f /�M Screen Length (from) (to) 5 <br /> �7 Filter Pack (from)� (to) <br /> Bentonite (from) 59 (to) So <br /> Inspector: Grout (from) To (to) D <br /> 16 <br /> Permit No. `�7 7 Drilling rig type c4"16- <br /> �/� 7 7 Auger O.D. $ I.D. <br /> -/ <br /> Drilling Company:- Completion - Stove pipe/christie box (circle one) <br /> 4--�/.-P <br /> Driller: casing <br /> height <br /> Consultant -�G- <br /> Geologist <br /> ABOVE-GROUND �x <br /> OOI.FLE CN O <br /> SPECIAL PERMIT INFO. Ground Surlacs <br /> Distance to sewer line grout <br /> Domestic well on site - (y n ) 5 D <br /> ft' <br /> If yes, location and distance - 455 <br /> SS tt. <br /> tt. - <br /> _ m <br /> a <br /> — o <br /> C <br /> SAMPLING slatted = c <br /> e C1 sec5on =HoldingTempera e = tame,Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet -LP, <br /> _ 0 <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - 2 tk c I PLC <br /> Location Casing type d� <br /> Blank S`; ft. Screen / ft. <br /> Slot size . O l O <br /> GROUTING �7V�rBags cement T .t <br /> ( <br /> Buckets bentonite I — CLQ <br /> Depth to water �S Bags sand/gravel <br /> Mix Ratios Z II t/ U Filter Pack type/size :211 <br /> Installation MethodSurge Block: - (y n <br /> Quantity Installed U Discussed with geologist: - (y <br /> Type of method <br /> EH 29 29 <br /> /5 <br />