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MONITORING WELL INSTALLATION REPORT <br /> Date: /Z l CONSTRUCTION <br /> Premise Address: Al. t' Z"r Total Depth <br /> / Screen Length (from) (to) <br /> Well No.:Ak' gyp[ . At A, 7 Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig e <br /> Permit No. Auger O.D.V� I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company:, aCQ& _ <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist.& _— few <br /> AWVE-GROUND MISTY-SOX <br /> DoirPiETtoNt,� IS 1f,,17 COMPLETION <br /> SPECIAL. PERMIT INFO. G'nd Suriace <br /> Distance to sewer line Qta�t <br /> Domestic well on site - (y/n ) 'Sa ft, <br /> If yes, location and distance - , <br /> ry.S p <br /> SAMPLING 4 slotted Y = G <br /> sac- an <br /> Holding Temperature ° <br /> � ;�,�: — gravel PackMethod ` <br /> Screening Me o : <br /> Tracking Sheet - (y/n) it <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) „ d <br /> Storage Location Q3 Casinge <br /> Blank ft. Screen 2 0 ft. <br /> Slot size 0-1>1D <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water q" d Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method .� Surge Block: - (y/ <br /> Quantity Installed Discussed with geologist: - L:/ n ) <br /> Type of method <br /> EH 29 29 <br />