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MONITORING WELL INSTALLATION REPORT <br /> Date:__ 1 X 1 md- 4��I� CONSTRUCTION <br /> Premise Address: Z n 15' n Total Depth b <br /> Screen Length (from) ` <br /> Well No.: yV�LQ - j to i- 1M lnJ - Filter Pack (from) z8k % (to) <br /> Iza— <br /> ;(to) oj <br /> Bentonite (from) zh ' _(to) �A'j <br /> Inspector: \l nuc. Grout (from) (to) <br /> Drilling rig type <br /> Permit No. S(L Z SS K S Auger O.D. I.D. <br /> Completion-Stove pipe/christie box (circle one) <br /> Drilling Company: �-)i.z� ,e i <br /> Driller:_ gena casing <br /> U height <br /> Consultant a=: 0 iff—T <br /> Geologist <br /> IN M— <br /> ABOVE-GROUND <br /> COMPLETION CHRISTY-BOX <br /> SPECIAL PERMIT INFO. GroundSurfaceCOMPLETION <br /> Distance to sewer line Cry <br /> Domestic well on site - (y/n <br /> If yes, location and dis e - �'-=-=--tt• <br /> m <br /> N <br /> SAMPLING <br /> . slotted <br /> wc4on ,.: <br /> H _ ' emperature w <br /> Method "�cc , <br /> --�i sfdah�.ti- I <br /> Screening Method Q 1 l7 <br /> Tracking Sheet - (y/ i < _ <br /> ko µ• <br /> SPOILS p <br /> Storage Method 5 S oULAK- MATERIALS/DEVELOPMENT <br /> Contamination Noted - (yc)) <br /> Storage Location• r^,4y Casing type 7z P V C <br /> BlankIQ fr. Screen z,o- ft. <br /> Slot size o'io <br /> GROUTING Bags cement n/ <br /> Depth to water N Bags sand/gravelets � , <br /> g N <br /> Mix Ratios `1'9 H l! Q, r, Filter Pack type/size s <br /> Installation Method <br /> x-44 Surge Block: - (y/n ) <br /> Quantity Installed 1 Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br /> M <br /> �I <br />