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' MONITORING WELL INSTALLATION REPORT <br /> Date: AI, U63 CONSTRUCTION d <br /> S� �' G L6 / Total Depth <br /> Premise Address: �b <br /> Screen Length (from) (to) 34 <br /> Well No.: r" '4j V £''O Filter Pack (from) Z St (to) 3 <br /> Bentonite (from) c-- (to) <br /> Inspector. Grout.Dilliri rype o (to) <br /> Auger O D. G �K I.D. �Y <br /> Permit No. ` Completion - Stove piPe�,I�tie box (circle one) <br /> Drilling Company: ro - ` <br /> �_ - casi <br /> Driller.' -- ?�� heig t <br /> Consultant <br /> Geologist AP.OVE-GRCUNO tSSY30X i <br /> COWPLETiON CO!iFtGflGtt <br /> -- <br /> Ground Suixt <br /> SPECIAL PERMIT INFO. <br /> prat <br /> Distance to sewer line3L - --(t <br /> Domestic well on site - (y/ n) tt <br /> If yes, location and distance - 3 X ft _ <br /> O <br /> - C <br /> O <br /> SAMPLING SQ'Ic <br /> socicn —_ <br /> Holding Temperature - <br /> Method <br /> Screening Method <br /> Tracking Sheet <br /> "- <br /> SPOILS rlq <br /> MATERIALS/DEVELOPMENT <br /> Storage Method'---- <br /> Contamination <br /> ethodContamination Noted- (y IR Casing typejr If Bpi/('/ <br /> Storage Location Blank •3X ft. Screen La _f <br /> Slot size <br /> Bags cement <br /> GROUPING Buckets bentonite <br /> i6�' Bags sand/gravel <br /> Depth to water - Filter Pack type/size 711 <br /> Mix Ratios Surge Block: - ( y/n) <br /> --,Installation MethodDiscussed v 'th geol gist: - (©/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />