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MONITORING WELL INSTALLATION REPORT <br /> Date:_ 4,I S to-L7 CONSTRUCTION <br /> Premise Address:_ai b S (taPn� I�bl - Total Depth_ ZO t <br /> Screen Length (from)_ AS ` (to)_ 101 <br /> Well No.:M(0-S Filter Pack (from) ` _(to)_ c i <br /> ^ Bentonite (from) <br /> %nspector._ 1�tnnn('o�`. Grout (from) _ (to)__ 3 <br /> .Drilling rig type <br /> Pen-nit No. Auger O.D. I.D. <br /> Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling Company: 1'$s�5" <br /> Driller:_ �Oy�V` casing <br /> T height <br /> Consultant `V <br /> Geologist � v <br /> • ABOVE-G B CUND CF-R:STl'2sOX <br /> COWl MON CSLET1CN <br /> SPECIAL PERMIT INFO. mrd Su-taxs <br /> Distance to sewer line Dra <br /> Domestic well on site - y/n) <br /> If yes, location an istance - <br /> vi m <br /> M <br /> SAMPLING <br /> socicn <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) - <br /> = — q rft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Cont4minadon Noted - ( /n} <br /> Storage LocationCasing type K <br /> Blank f[. Screen <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water r�j C6 Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> 4pstallation Method Surge Block: - (y/n ) <br /> Quantity Installed Discussed vrith geologist: - (y/n_ } <br /> Type of netliod <br /> EH 29 29. . <br />