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MONITORING WELL INSTALLATION REPORT <br /> Date:_ _ ?i I I C� CONSTRUCTION <br /> Premise Address: LC> .i C) <br /> o Vn p eA A Total Depth I oq. <br /> Screen Length (from) 4q (to) 4q- <br /> Well No.: l/J ' 1 Filter Pack (from) q1j (to) yQg_ s <br /> Bentonite (from) T G (to) <br /> Inspector: Grout (from) (to) q_ <br /> Drilling rig type <br /> Permit No. Auger O.D. � 'z s "" I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company:_ (1 <br /> Driller: � casing � <br /> height <br /> Consultant .� a,�—t...� � 'd <br /> Geologist_ ScoAA _ T <br /> —E <br /> ABCVE-GACUND CtiAISTY-30X <br /> CCI�L�fION com EnCN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line gfeut <br /> Domestic well on - ( y/ n) <br /> 11'yes, Iota ' and distance - ft <br /> — a <br /> _= m <br /> = o <br /> — c <br /> SAMPLING = <br /> slorcd — c <br /> sacicn <br /> Holding Temperature <br /> Method — <br /> Screeninzthod r <br /> Trac ' g Sheet - ( y/ n ) _ <br /> 1 q•yft. = 0q, tette <br /> SPOILS p <br /> Storage Methodnr"w - MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location_ , c. ( Casing type <br /> Blank 11, -5- ft. Screen 16 ft. <br /> Slot size - OL(--) <br /> GROUTING Bags cement N 2 0 <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel 3 K2, (� <br /> Mix Ratios ( c+ s 5' c t M iy-eo Q Filter Pack type/size <br /> Installation Method" <br /> �� Surge Block: - (y/ n ) <br /> Quantity Installed n z-��_ . A,l __ Discussed with geologist: - ( y <br /> EH 29 29 Type of method <br />