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MONITORING WELL INSTALLATION REPORT <br /> Date: M-?/I 7 q� �y � CONSTRUCTION <br /> Premise Address:r -tp?� ' '(' ° ' ` " r N� Total Depth ( <br /> '� � �-// Screen Length (from) LS (to) (Sb <br /> Well No.: till 'v �r^^ �� Filter Pack (from) 2P (to)ITT— <br /> Bentonite (from) I`f� (to)IT) <br /> Grout (from) 14° (to)75 <br /> Drilling rig type ��.hA U <br /> Inspector. <br /> Permit No. Auger O.D. 1 / I. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: f <br /> �� casing <br /> Driller: height <br /> Consultant }LtcDZ <br /> Geologist bu , S" MjAAgpyE GACUNp <br /> coWLE'DON CC.OMPL..R1CAtLEMx <br /> N <br /> SPECIAL PERMIT INFO. '-------=Ground Suite <br /> praA <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) I�0 It• <br /> If yes, location and distance - <br /> — - m <br /> - = o <br /> — o <br /> dorsi <br /> SAMPLING soden — <br /> Holding Temperature A = g1P91 F� <br /> Method <br /> Screenino Method — <br /> Tracking Shcet - (y/ n) <br /> SPOILS <br /> Storage Method L MATERIALS/DEVELOPMENT <br /> Contamination Noted (y/n ) �N QU(J $6 <br /> Storage Location gl�Casing .[! h. <br /> fc Screen 6 <br /> Slot size 0 O?A — <br /> GROUTING Bags cement — <br /> Buckets bentonite l00 <br /> Depth to water ' Bags sand/gravel <br /> Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/ n ) <br /> Installation Method Discussed with geologist: - (0/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />