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MONITORING WELL INSTALLATION REPutZT <br /> Date: 6. 17 ., fq n / CONSTRUCTION <br /> Premise Address: 52I N , l klK�r Total Depth JlG1 <br /> Screen Length (from) 6,17 (to) 39 <br /> Well No.: /('ZZ Filter Pack (from) 6r7 (to) 3-7 <br /> Bentonite (from) 5-7 (to) 'Z4 <br /> Inspector: nJ• GCt4-t L'-1 bl�._ Grout (from) 34- (to) - <br /> Drilling rig type <br /> Permit No. �� I l 4 Auger O.D. <br /> �N�U Completion - Stove pipe c stie bo: (circle one) <br /> Consultant <br /> Geologist VIM(L Cie—avt , stck•up <br /> .1177V-T. -QVT <br /> SPECIAL PERMIT INFO. ABOVE•GROUNO <br /> COMPLEr10N CHRISTI'-80X <br /> 450Distance to sewer line LCOMPLETION <br /> Domestic well on site - (y/(r ) G=nd S <br /> If yes, location and distance - <br /> 0tout <br /> n. <br /> n. <br /> m <br /> SAMPLING — • <br /> o <br /> Holding Temperature L}oC. slotted = 'E <br /> Method lCA S- **cion x• — <br /> Screening Method � M. _ gnval pack <br /> Tracking Sheet n) <br /> SPOILS <br /> Storage Method a"'fryt: MATERIALS/DEVELOPMENT <br /> Contamination Notes - (y/ n ) <br /> Storage Location h1.1 e. Casing type 4-' coo 4D R/G <br /> Blank 3 ft Screen Zv <br /> Slot size D. O? to <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> i Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Ratios MI Surge Block: - ( y/0) <br /> Installation Method Discussed with geologist: - n ) <br /> Quantity Installed Type of method <br /> -}` UAa .S ozM kouTrw� Ia e,r Hr f ( �cRsL�> <br />