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MONITORING WELL INSTALLATION REPORT <br /> Date: ci `l �I �U <br /> —� CON�ON <br /> Premise Address:_l( I d S- Mc <br /> Total Depth p <br /> Well No.:_ (y -`p�. l03-(off Screen Length (from) <br /> Filter Pack (from) <br /> Inspector. V1Bentonite (from) qy. S <br /> Grout (from)— --(ro) a <br /> Permit No,- � IO � Drilling rig (to) <br /> Permit <br /> 3 type <br /> Auger O.D. I.D.�— <br /> Drill ng Company:_ F Completion - Stove pipe/chrisde boz (ctrcle one) <br /> Driller. <br /> �_ casing <br /> Consultant L� �(` � " height <br /> Q <br /> Geologist (�c� f1 <br /> A3CVE-GACUND ^ <br /> SPECIAL, PERMIT INFO. C0&VLH'rCN GAST1 dOX <br /> Crtt:nd Strfxy <br /> Distance to sewer line r <br /> Domestic well on site - (Y/ grout <br /> If Yes, location and dista <br /> �•S ' it. <br /> �_h• ft. <br /> SAMPLING = o <br /> _ c <br /> Holding Temperature socio <br /> Methodeenin, % Q�� <br /> _Sib it ( toe cn — S <br /> Screenin, .66 <br /> Method = ic <br /> TrackingShcet y/ nSPOILS .ft• = ft, <br /> Storage Method /110 tl <br /> Contamination Noted • ( ) MATERIALS/D��OpMENT <br /> Storage Locar'on �Sr _ a <br /> o n � <br /> Casing type_ 2 <br /> GROUTING Blank I- -a ft Screen S <br /> � Slot size <br /> t Bags cement <br /> Dep h to water nJ (,O-6$ Bags sanbentorite <br /> Mix Rat os c <br /> Installation LS g d/gravcl <br /> Metho Filter Pack type/size <br /> Quantity Installed Surgc Block: - (Y n <br /> Discussed with geologist: - (y <br /> EH 29 29 Type of method <br />