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MONITORING WELL INSTALLATION REPORT <br /> Date:_ _I z3l p z� CONSTRUCTION <br /> tT <br /> Premise Addressu:)no "- 0� lr\ a � Total Depth �( <br /> Well No.: {yl lA� - Screen Length (from) (to)�i <br /> Filter Pack (from) t (to) a,N <br /> inspector. _ inn rrn t.� Bentonite (from) t (to) <br /> Grout (from) <br /> Permit No, X 5 Drilling rig type <br /> — —�� Auger O.D. I.D. <br /> Drilling Company._Com an ._ Completion -Stove pipe/christie box .(cir('ovnr�r�A <br /> Driller._ Qo AAA <br /> ^..._ casing <br /> Consultant (--1� height <br /> O '4 <br /> Geologist_� � T <br /> T <br /> ABOVE-GACUND <br /> CONPLEMN CHRLT -aox <br /> SPECIAL PERMIT INFO. COMPL.ETICN <br /> s-----���C3tvund Stsfan <br /> Distance to sewer line orart <br /> Domestic well on site - (y <br /> If yes, location and ance - cco�qq _ JLS (t <br /> SAMPLING = c <br /> doral _= c <br /> Holding Temperature 10` 0" <br /> Method <br /> Screening Method �I n <br /> Tracking Sheet n ) <br /> SPOILS _= <br /> tt. — It. <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y ) - <br /> Storage Location i� <br /> Casing type. Z PV <br /> Blank��9 ft Screen eft, <br /> GROUTING Slot size .ozid <br /> Bags cement <br /> Depth to water z Buckets bentonite <br /> Mix Ratios Bags sand/gravel ry <br /> Installation Method Filter Pack type/size <br /> Quantity Installed Surge Block: - (yt <br /> Discussed with geo zis[: • (y <br /> EH 29 29 Type of method <br />