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MONITORING WELL INSTALLATION REPORT <br /> Date:-� � / CONSTRUCTION <br /> Premise Address:'/0_.:5_S_. /�a,-z� SToc��f`v Total Depth .rte <br /> Screen Length (from) '3 S (to) <br /> Well No.:.�1 U_/ Screen <br /> Pack ( <br /> from) S (Lo) l <br /> Bentonite (from) i (to)_ <br /> Inspector: Grout <br /> (from)_ (to)-,_ <br /> Drilling rig type_ C,� r <br /> Permit No. > pz, -7/ 0� -Z Auger O.D._ R ` I.D. <br /> Drilling Company: r qs � ,, ��: <br /> Completion - Stove pipe/christie box (circle one) <br /> Driller:_ <br /> casing <br /> Consultant_ 1�d�..w height <br /> Geologist r4vc�•�<,I G�,,,,� .' <br /> ABOVE-GROUND <br /> SPECIAL PERMIT INFO. <br /> 00k9LET10N C-isZ7y-c30X <br /> COMIPLETION <br /> -- Ground Suriaca <br /> Distance to sewer line <br /> Domestic well on site - (y/n ) grout <br /> If yes, location and distance - <br /> �`5 ft. <br /> m <br /> _ a <br /> SAMPLING .= m <br /> v' C <br /> o <br /> c <br /> Holding Temperature <br /> Method __ <br /> Screening MethodVIV91 Pack <br /> Tracking Sheet - (y/ n ) <br /> SPOILS —eft' S n. <br /> Storage Method <br /> Contamination Noted - (y/n ) MATERIALS/DEVELOPMENT <br /> Storage Location <br /> Casing t)Te_ L I/6i <br /> Blank 2� ft. Screen / <br /> TI <br /> GROUNG <br /> Slot size o R' <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios Bags sand/gravel z <br /> Installation Method Filter Pack type/size_ <br /> Quantity Installed Surge Block; - CP n ) <br /> Discussed with geologist: - (y/ n ) <br /> EH 29 29 Type of method <br />