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MONITORING WELL INSTAII.ATI0AkiP0RT <br /> Date: (7 I I I b CONSTRUCTION <br /> Ir <br /> Premise Address: L D L 1 Ln «+ I/u Total Depth <br /> Screen Length (from)—(to) <br /> Filter Pack (from) fo (to) Zr <br /> Well No.: Y1n I'17 Bentonite (from) S� (to) 60� <br /> Inspector: D%ti Grout (from) _(to) 15'3/ <br /> Drilling rig type <br /> –q p <br /> Permit No. 5 La <br /> Auger O.D. LD. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: Aw j AX MM i&Aon� <br /> casing <br /> Driller: height <br /> Consultant /�//��1"(^�— T <br /> S i �cfl_B�� Fc A80VE GROUNDpISTY BOX r <br /> COMPLETION COMPLETION <br /> Drourd Surf acs <br /> SPECIAL PERMIT INFO. <br /> grout <br /> Distance to sewer line --- <br /> Domestic well on site - AD <br /> If yes, location and ance - H• <br /> n• — <br /> a <br /> 0 <br /> O <br /> SAMPLING <br /> axon — <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - ®/ n ) <br /> Ott• — Z tt. <br /> SPOILS <br /> Storage MethodS S MATERIALS/DEVELOPMENT <br /> Contamination Noted • (y n ) <br /> Storage Location MpaI Casing type tr PVC S <br /> Blank ft. Screen-- <br /> -I 7 ft• <br /> Slot size .07,0 <br /> GROUTING Bags cement ^/ 1Z <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel .S git <br /> Mix Ratios (.� / Filter Pack type/size ` <br /> Installation Method — Surge Block: - ( y n ) <br /> Quantity Installed n, Discussed with geologist: - ( y <br /> Type of method <br /> EH 29 29 <br /> C rlv✓ <br />