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j.,. / MONITORING WELL INSTALLATION REPORT <br /> Date : / 7 9Zf -- // CONSTRUCTION <br /> Premise Address : - 6 /U4 OOZR� Total Depth r <br /> '/ q Screen Length (from) a (to) 3 S <br /> Well No. : yly / �J'�Z Filter Pack (from) (to) 3� <br /> T Bentonire (from) 3 (to) 3 Z <br /> Inspector: 4L Grout (from) Z (to) n <br /> q Drilling rig type GMS 5 <br /> Permit No. / 2 Z l3 Auger O .D. t /z I.D. <br /> Drilling Company: Completion - Stove pipe/chrisde box (circle one) <br /> casin� //!� <br /> Driller: l�G Lca of F �j _ � height <br /> Consultant / <br /> Geologist ABOVE-GROUND <br /> COMPLETION CHRISTY-acx <br /> Ground Surf act <br /> SPECIAL PERMIT INFO . <br /> grout <br /> Distance to sewer line 7TC> <br /> 2— ft. <br /> Domestic well on site - ( y /la) $ <br /> If yes, location and distance <br /> — a <br /> o <br /> dotted —_ c <br /> SAMPLING taction <br /> Holding Temperature 6m>t ''VV' Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y / n ) <br /> SPOILS <br /> Storagg Method t r ^^� " " � 09 MATERIALS/DEVELOPMENT <br /> Contamination Noted - n ) <br /> Storage Location ak Casing type <br /> Blank ft. Screen • ZS fr. <br /> Slor size / <br /> GROUTING Bags cement <br /> Buckets bentonite t L <br /> Depth to water Bags sand/gravel z <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - C v� oul>A <br /> Quantity Ins(alled Discussed with geologist: - ( y / n ) <br /> Type of method ' / <br /> N� / "/4 <br /> m coo N° r <br />