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MONITORING WELL INSTALLATION REPORT <br /> Date: 11 ZZ-'71--N / CONSTRUCTION <br /> Premise Address: 403'5 1/(/ MI IAS 4- Total Depth 111 <br /> Screen Length (from) I of& (to) lit <br /> Well No.: Filter Pack (from) la,( (to) III <br /> Bentonite (from) ` ' (to) Io4 <br /> Inspector: Grout (from) 6 (to), Try <br /> Drilling rig type <br /> Permit No. S 5 q Z Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: 6 4cA" casing <br /> height <br /> Consultant n � <br /> Geologist <br /> ABOVE-GROUND CHRISlY-BOX <br /> COMPLETION _.COMP1ETIcN - <br /> -- SPECIAL PERMIT INFO. Ground Saiaca <br /> Distance to sewer line grout <br /> Domestic well on site - y/ n <br /> if yes, location an istance - <br /> _ m <br /> a <br /> o <br /> C <br /> o <br /> SAMPLING alottad = S <br /> wdon —_ <br /> Holding Temperature CrIA l'C^ = gavel Pw�" <br /> Method <br /> Screening Method '� x <br /> Tracking Sheet - y n ) 8. <br /> SPOILS <br /> Storage MethodS S oln MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y —0 <br /> Storage Location am5i fn Casing type 7 " eyc <br /> Blank t06 ft. screen----5—ft. <br /> Slot size ozD <br /> GROUTING Bags cement 6 <br /> Buckets bentonite t <br /> Depth to water Bags sand/gravel N3 <br /> Mix Ratios 7- Filter Pack type/size3 l_,� U. smaea/-, <br /> Installation Method -t%t � Surge Block: - W/ n ) <br /> Quantity Installed x g"O .+er ( Discussed with geologist: - ( y/0) <br /> Type of method <br /> EH 29 29 <br />