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MONITORING WELL INSTALLATION REPORT <br /> Date: /7a/�-I A CONSTRUCTION <br /> Premise Address: d. .jb-,w , 1Q� Total Depth <br /> ' Screen Length (from) (to) <br /> Well No.: -)S� LA,Sn,s I , GASM Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. DD S Z8 3 Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company:��/LtC/S <br /> Driller: casing <br /> height <br /> Consultant w"j <br /> YQ <br /> Geologist 419 <br /> ABOVE-GROUND <br /> COMiPLE-f10N CNRLM-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface T -- <br /> 011*7 <br /> Distance to sewer line Vz, Cf0ut <br /> Domestic well on site - (y/n ) <br /> If yes, location and distance - ft. <br /> ft. ft. <br /> - C <br /> - O <br /> SAMPLING slotted <br /> aQc�on — <br /> Holding Temperature grave,Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/n ) 4. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) b <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size O.o" <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y/n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />