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MONITORING WELL INSTALLATION REPORT <br /> Date:_ Lj � , 1 ti CONSTRUCTION <br /> Premise Address:_�(�� _(��� �5�, � Crifivv, Total Depth , <br /> Well No.: MW - Screen Length (from)' (nri (to) _ <br /> Filter Pack (from) (to) <br /> Inspector: Bentonite (from)CPoZ (to) �2C� <br /> Grout (from)_ <br /> Permit N Drilling rig a Fl II mA� Stpyy l <br /> Auger O.D. <br /> Drilling Company;_O <br /> Completion- Stove pipe/ 'stie box circle one) <br /> Driller: casing <br /> ` \ height <br /> Consultant <br /> Geologist L6Q.ty <br /> ABOVE-GROUND C�fA1S7Y-BOX - <br /> CON?LET{ON <br /> SPECIAL PERMIT INFO. COMPLEnON <br /> Ground j�riacv <br /> Distance to sewer liner„O� grout I <br /> Domestic well on site - (y/n) lY % t <br /> If yes, location and distance - (P o- S ft. <br /> LOn, fi. <br /> NS <br /> • O <br /> SAMPLING v <br /> • slatted ..r — c <br /> Holding Temperature = P <br /> Method — <br /> ack <br /> Screening Method = <br /> Tracking Sheet - (y/n) --�� - <br /> SPOILS S $b <br /> Storage Method SS A 6(LM LMW5 ( y'. MATERIALS/DEVELOPMENT <br /> Contamination Noted - (yJ A) <br /> Storage Location_ S1 V- Casing type sckfjd,qb <br /> Blank 3 ft. Screen ft. <br /> Slot size D.QI'' <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size 'Sl*7, ms-y\1" .sa-hA <br /> Installation Method Surge.Block:_=(.y_/_n-) <br /> Quantity Installed Discussed with geologist: - (y/n) <br /> Type of method <br /> EH 29 29 <br />