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MONITORING WELL INSTALLATION REPORT <br /> Date: y p_i CONSTRUCTION <br /> Premise Address:_ Z o 10 9 5• Vtnn cc,k ()j Total Depth 2 7 <br /> Screen Length (from) IV (to) f <br /> Well No.: Filter Pack (from) g (to) Z 1 <br /> Bentonite (from) <br /> Inspector: 6 wv\C o,,, Grout (from) (to) <br /> Permit No. 30 ( 0 Drilling rig type_ <br /> Auger O.D. I.D. <br /> Completion �Pipe <br /> hristie box (circle one) <br /> Drilling Company: \j + <br /> Driller: casing <br /> height <br /> Consultant }�QnM.lc..����. <br /> Geologist Seaa 1Pov ok- <br /> ABOVE-GROUND <br /> COMPLETION CHRZTY-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surlwo <br /> Distance to sewer line Crouty <br /> Domestic well on site - (y <br /> If yes, location and dis a n' <br /> _l.d ft. ft. <br /> i+= A <br /> C <br /> SAMPLING = ° <br /> •lotted � <br /> wcton <br /> Holding Temperature = . <br /> Method _ v"�pack <br /> >-. <br /> Screening Method = — <br /> Track"eet - ( y/ n ) <br /> SPOILS <br /> Storage Me od— MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Stor6ge Location Casing type 2 VC <br /> Blank Lo ft. Screen 1) 5— ft. <br /> Slot size , 020 <br /> GROUTING Bags cement Z d <br /> Buckets bentonite N <br /> Depth to water ry ,l Bags sand/gravel of <br /> Mix Ratios Filter Pack type/size <br /> Installation Method ('o1&� f, Surge Block: - (y'00 <br /> Quantity Installed N 1 n c-c& Discussed with geol-ogist: - (y <br /> Type of method <br /> EH 29 29 <br />