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~MONITORING WELL INSTALLATION REP(�r <br /> Date: 5 ' 17 ' 7``� CONSTRUCTION <br /> Premise Address: '1Z� h/ • YZc7)Ck Lr Total Depth <br /> Screen Length (from) Cao (to) 4-o <br /> Well No.: 3 Filter Pack (from) la o (to) 3¢; <br /> ¢ �� � pBentonite (from) 3A (to) '3 b' <br /> Inspector: d. cc at�[SY�(lR , Grout (from) sS (to) ,9- <br /> �J I II 3 Drilling rig type <br /> Permit No. Auger O.D. <br /> �^ � � Completion - Stove pipe/ stie box (circle one) <br /> Consultant Yp�'C.Ce7Y. <br /> Geologist V I CTO/1- ((4-LI-a'491i *tk*-up <br /> SPECIAL PERMIT INFO. ABOVE-GROUND <br /> CHAI5TY-80X <br /> Distance to sewer line f COMPLETION COMPLETION <br /> Domestic well on site - (y/D Ground Surface <br /> If yes, location and distance - grout <br /> tt. <br /> n. <br /> O <br /> SAMPLING <br /> Holding Temperature 40C- slotted <br /> Methodmon $ <br /> Screening Method = pnwlpack <br /> Tracking Sheet - 0/ n) j <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Notes - (y/ n ) <br /> Storage Location Casing type 04 5-�) PlC� <br /> Blank 4U ft. Screen 2Zo ft. <br /> Slot size �•O ZO <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water 4�S Filter Pack type/size �J <br /> Mix Ratios 9 I t I Surge Block: - (y 0) <br /> Installation Method Discussed with geologist: - n ) <br /> Quantity Installed Type of method <br /> -A Ids Coyn Ouao-) uPo� �n2lv,Q ( u3�ssr � t- <br />