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MONITORING WELL INSTALLATION REPORT <br /> Date:_ � ' ZO / p CONSTRUCTION <br /> Premise Address:�[ yY r%Cj,\ - Total Depth_ TIC;- <br /> Well <br /> SWell No.: Screen Length (from)_ S'S–` (to)— <br /> Filter Pack (from)_ S'Z (to) <br /> Inspector. Bentonite (from)__ yy_(to)--' — <br /> r Grout (from)_ (to) <br /> Permit No. ; S Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Company._ CAMf' Completion - Stove pipe/ tie bos (circle e� <br /> Driller._ ern 4A4 <br /> casing <br /> Consultant - �4 11 height <br /> 4 � <br /> Geologist 0 Y M1 <br /> ABCVE-GAC(JND <br /> CCkFL TICN Ci-USTY-aox ' <br /> SPECIAL PERMIT INFO. CCMPLL`?iCH <br /> Cvu:nd Suint <br /> Distance to sewer line <br /> Domestic well on site - grout <br /> If yes, location an istance n) <br /> So <br /> syto Z- <br /> S AM?LJ N SAMPLIN = c <br /> 0 <br /> ilorai _= c <br /> Holding Temperature atcicn <br /> Method <br /> Screening Me yactt <br /> Trackin cec - (y/ n ) <br /> SPOILS —L—fl. <br /> Storage Method <br /> Contamination Noted - y, n MATERIAL.B/DEVE[OpMENT <br /> Storage Location iyt, � <br /> Casing type 2 � p),'C <br /> Blank_ S f- Screen 7 <br /> GR_ 0U-ncNG Slot size oZo <br /> Bags cement I <br /> Depth to water r Buckets bentonite / <br /> Mix Ratios Bags sand/gravel %v <br /> Installation Method Filter Pack type/sizeZj tyµ p^Q <br /> n� zpe� Surge Block: - C Y <br /> Quantity Installed tt � <br /> Discussed with geologist: - (y cn' � <br /> EH 29 29 Type of method <br />