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MONITORING WELL INSTALLATION REPORT <br /> Date: �I z �O�d CONSTRUCTION <br /> Premise Address: 9 -og "4(c 12�E Total Depth �O <br /> Screen Length (from) (o (to) fra <br /> Well No.: yj - 6 l a-- Filter Pack (from) qt- (to) t`sG <br /> Bentonite (from) 4-6 (to) _ <br /> Inspector: AA -rAn Grout (from) t L (to) sb <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> -ev��rnr,F w , <br /> Driller: Aw'a'J6casing <br /> height <br /> Consultant��� (� <br /> Geologist •- <br /> ABOVE-GRCUND CNAISTY-80X <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surf <br /> Distance to sewer line grout <br /> Domestic well o e - (y/n ) _tt <br /> If yes, locat' and distance - ft <br /> (�n tt. <br /> q <br /> 9 <br /> C <br /> SAMPLING, _ _ dotted <br /> axion <br /> Holding Temgr.perature = P <br /> Method <br /> Screen' ethod s <br /> T g Sheet • (y/ n) <br /> `60 <br /> SPOILS p <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Oyi si fk Casing type .tie�' kc] PVC. 4 0�'4 <br /> Blank 6n ft. Screen 7 o ft. <br /> Slot size o�(� <br /> GROUTING Bags cement <br /> Buckets bentonite I - "u - vs XAA <br /> Depth to water �V Z 5 tC.sY Bags sand/gravel 12, <br /> Mix Ratios Filter Pack type/size A4 i l La <br /> Installation Method 1ox.a.. -qAsu 9A'lrwn r_ Surge Block: - ( y/® <br /> Quantity Installed Discussed with geologist: - <br /> Type of method +/( <br /> EH 29 29 <br />