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MONITORING WELL INSTALLATION REPORT <br /> Date: ���II CONSTRUCTION <br /> Premise Address: I J6 I psi 4 IA,c1 Total Depth 3 S <br /> Screen Length (from) 17 (to) <br /> Wel] No.: W - I Filter Pack (from) I (to) <br /> Bentonite (from)�1-�(to)__�3 <br /> Inspector; 1D yMCeN Grout (from)— (to) 1 <br /> _ Drilling rig type �Fr12 <br /> Permit No. /0 9 5 Auger O.D. I.D. <br /> p <br /> Drilling Company: �i Completion - Stove pipe/clu-istie box (circle one) <br /> � � �two� C` <br /> Driller: ✓ casing <br /> height <br /> Consultant �t,�ti)A7,>-1.�` <br /> Geologist Rx2 tnn 4 /VENO i <br /> ABOVE-GROUND <br /> COMPLETION CHRLM-BOX <br /> &OMP-LTION <br /> SPECIAL PERMIT INFO. Ground Salla e <br /> Distance to sewer line of0 I <br /> Domestic well on site y/ n ) <br /> If yes, location distance - ft' <br /> i ft. <br /> = m <br /> — o <br /> = m <br /> SAMPLING dotted = c <br /> axion — <br /> Holding Temperatur <br /> Method = V1fBI Pz <br /> Screening thod = <br /> Trackin beet - (y/ n ) <br /> SPOILS // <br /> Storage Method {6 I H�X MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location p la 51- Casing type Z <br /> Blank ft. Screen ^ko ft. <br /> Slot size #n I o <br /> GROUTING Bags cement <br /> Buckets bentonite I / <br /> Depth to water N O I Bags sand/gravel S <br /> Mix Ratios Filter Pack type/size v12- <br /> Installation <br /> ZInstallation Me d Surge Block: - ( y/0) <br /> Quantity Installed Discussed with geologist: - (y/(q) <br /> Type of method <br /> EH 29 29 <br />