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MONITORING WELL INSTALLATION REPORT <br /> 512�I9,4 <br /> Date: CONSTRUCTION <br /> ti <br /> Premise Address: - -5 to- Total Depth <br /> Screen Length (from) 3 (to) Zo <br /> Well No.: Filter Pack (from) (to) /8 <br /> Bentonite (from) /� (to) <br /> Inspector: `bVV�� Grout (from) (to) <br /> Permit No. 6C 25 2( (3f2Z-014� Drilling rig type �a.D 4' <br /> Auger O.D. I.D. <br /> I'C �� Completion - Stove pipe/ uistie box (circle one) <br /> Drilling Company: �/ C-�YL�(.t.(��1'�. Cl��� :-� F�� '�(lU.t•� <br /> Driller: <br /> /�Im C <br /> c nq <br /> height <br /> Consultant F117 V <br /> Geologist VM <br /> ABOVE-GRCUND CHSZT'Y-BOX <br /> COAFLErION <br /> COMPI.rcTICN <br /> SPECIAL PERMIT INFO. Ground Surfacs <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) ft. <br /> If yes, location and distance - <br /> �• ft. <br /> SAMPLING <br /> '• o <br /> •lot•.o.9 <br /> asc1cn -' <br /> Holding Temperature _ F <br /> Method <br /> Screenin;Method t' <br /> Tracking Sheet - (y/ n ) r' — <br /> —ft.�... tt. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ <br /> Storage Location Casing type P C l <br /> Blank 20r ft. Screen 10 ft. <br /> Slot size �? <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water_ Bags sand/gravel <br /> Mix Ratios au Tt ITT¢� 1-q4 ZT7 una, 1,4 Filter Pack type/ ize 3 <br /> Installation Method Surge Block: - n ) <br /> Quantity Installed Discussed with geologist: - XV\n ) <br /> Type of method <br /> EH 29 29 <br /> V U <br />