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MONITORING WELL INSTALLATION REPORT <br /> Date:'6O'�) CONSTRUCTION <br /> Premise Address: /t'oj-) C� � R Total Depth <br /> )Y )PA rQ� Screen Length (from) (to) <br /> Well No.: S 1 Filter Pack (from) (to) <br /> / I �J p p Bentonite (from) (to) <br /> Inspector: { l�✓✓ ( Grout (from) _ (to) <br /> Drilling rig type �6� -c, <br /> Permit No. AugQLO.D_ /0 " I.D. <br /> Drilling Company: <br /> impletion - S ove pipe/christie box (circle one) <br /> �� q�1p°�� 7 <br /> Driller: casing <br /> height <br /> Consultant S�� <br /> Geologist .. <br /> -ABOVE-GROUND <br /> COM?LETION C <br /> COOMPLMPLY-80X <br /> ETION <br /> SPECIAL PERMIT INFO. Ground Surfwv .� <br /> Distance to sewer lineproof_ (�,., <br /> Domestic well on site - ry)l n ) ISO b b <br /> If yes, location and dist ce - .SS <br /> -)0 ft. ft. <br /> 100 — E <br /> C <br /> O <br /> SAMPLING vl't $lotted <br /> /IQo sac on <br /> Holding Temperature ti�4 lIy <br /> Method = �`�P <br /> ack <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> t3q - tt. <br /> alR�� <br /> SPOILS 21i 13S <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type � a Pl/L s 5 <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water <br /> 1/2,U r3 S C� Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />