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MONITORING WELL INSTALLATION REPORt <br /> Date:/� S / ( Jf/r { CON ON <br /> / I / S <br /> Premise Address: 3/�f S� Db-) GLe� Total Depth Ze 2s / /ri <br /> \ T j Screen Length (from).Vo). <br /> Well No. : ) � Filter Pack (from) (too) <br /> Bentonite (from) (to) <br /> Inspector: ✓ t G Grout (from) (to) <br /> Drilling rig type <br /> Permit No. ZO ORSZ69 Tv-wg - 4a4pl 15" ZL^'3 Auger O.D._ I.D. <br /> / Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: /ti - 5 ��� <br /> Driller: casing <br /> height <br /> Consultant �G � __� <br /> Geologist 77 - \ <br /> ABOVE,GAOUND CNAISTY80X <br /> COf�LETZN COMPLETION <br /> SPECIAL PERMIT INFO. Ground Sutfx+ <br /> Distance to sewer line 4A <br /> grout <br /> Domestic well on site - ( y / n ) <br /> If yes, location and distance <br /> 3 ' Y6 <br /> SAMPLING olored <br /> G soclen = <br /> Holding Temperature y = F <br /> Method <br /> Screening Me od Ct// <br /> Tracking Sheet n ) <br /> fL <br /> SPOILS <br /> Storage Method ////p MATERIALS/DEVEI,OPMENC <br /> Contamination Note/ n ) <br /> Storage Location Casing type,,.-__ <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water �� Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Methods1,aV �t tS(� e Surge Block: - ( ,v / n ) <br /> Quantity Installed Discussed with geologist: - ( y / n ) <br /> Type of method <br /> EH 29 29 <br /> OV �/ i <br />