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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION nem loe) ' <br /> 940 yo ' <br /> Premise Address:_ 3 / � 7 S ' �ia �J Total Dept1 X70) 90 <br /> Screen Len (from) geD (to) Cna— <br /> Well No. : M Filter Pack (from)_ 90 (to) 78 <br /> Bentonite (from) 98' (to) 7;' <br /> Inspector: O Z Grout (from) (to) r <br /> PJJ� Drilling rig type <br /> Permit No. id Auger O.D. ;W f " LD. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: A /rnz /4 t <br /> 3a <br /> Driller: SCs � � s l6Y casing <br /> height <br /> Consultant75 <br /> Geologist T;� Cu✓ (/Au <br /> ABOVBGRCUND CHRiS7Y30X <br /> � p 0OMPL` 710N LIJ <br /> CCMPLEMCN <br /> SPECIAL PERMIT INFO, ONurd Surtan <br /> grout <br /> Distance to sewer line 2D <br /> Domestic well on site - ( y / tom) ft, <br /> If yes, location and distance <br /> h. <br /> SAMPLING S u ..ya �' u G�ri!``� Q doCoi = C <br /> Holding Temperature L <br /> Method <br /> Screening Method = <br /> Tracking Sheet - ( y / n ) <br /> SPOILS ) <br /> Storage Method 0Hu MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( ®/ n ) <br /> Storage Location Casing type_ <br /> Blank ft. Screen ft. <br /> Slot size wr9 <br /> GROUTING Bags cement io<aZ 7 fudge= <br /> Buckets bentonite <br /> Depth to water N Z � / Bags sand/gravel y z— <br /> Mix Ratios Filter Pack type/size 'z rZ <br /> Installation Method Surge Block: - (M/ n ) <br /> Quantity Installed Discussed with geolggist - �/ n ) <br /> Type of method hA AX <br /> 29 29 <br /> G I <br />