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MONITORING WELL INSTALLATION REPORT <br /> Date: `'� ZS � � CONSTRUCTION <br /> Premise Address: z-qo, L . r--t rAo(­4 5 Total DepthJ <br /> Screen Length (from) (to) S <br /> Well No.: V f��- 4 Filter Pack (from)„ (to) S <br /> Bentonite (from) (to) 3' <br /> Inspector: tli MSD+ L _ Grout (from) _(to) Li1' _T <br /> Drilling rig type <br /> Permit No. O l 6 Auger O.D. Al-i' _ I.D. <br /> Completion - Stove pip sue o (circle one) <br /> Drilling Company: - <br /> Driller:, Ena" casing <br /> ♦ height: <br /> Consultant —VEW7F <br /> Geologist _=i��//++QQCf/ ND <br /> COWLEi NN C-OMPLEMN <br /> SPECIAL PERMIT INFO. C3=nd Stacy <br /> Distance to sewer.line 2- grout <br /> Domestic well on site - (y/0 <br /> If yes, location and distance - _ -3 <br /> m <br /> C <br /> SAMPLING ilcrtad c <br /> sac-on <br /> Holding Temperature `� 9r%VW <br /> Pack <br /> Method <br /> Screening Method P t D <br /> Tracking Sheet - ( y/n ) :. <br /> Ott. = b 5 & <br /> SPOILS <br /> Storage Method A e-r�\ MATERIALS/DEVELOPMENT <br /> Contamination Noted -I y/n } , <br /> Storage Location n�- 5-t Casing type 2 <br /> Blank LI S fL Screen z 0 fL <br /> Slot size O =n-2 <br /> GROUTING Bags cement g <br /> Buckets bentonite I (w. <br /> Depth to water S - Bags sand/gravel 00 C <br /> Mix Ratios Filter Pack type/size <br /> Installation Method+.�cw.K.�3 1.bsc �� 'rr./��au� -+5 Surge Block: - n ) <br /> Quantity Installed ti Discussed with geologist: - i n) <br /> Type of method--2- <br /> EH <br /> ethodzEH 29 29 <br />