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MONITORING WELL INSTALLATION REPORT <br /> Date:_ /� /S — / y CONSTRUCTION <br /> Premise Address:_ f 7 /7 6 � Total De th <br /> P <br /> Well No.: �,/�_ — Screen Length (from)' (to) 5 <br /> Filter Pack (from) (to) — <br /> 11-16AII, Bentonite' (from)_ _A (to) <br /> Inspector: _ I� L"( Grout (from) (to) <br /> Permit No. <br /> �li2�,fo7�0(o Dulling rig e <br /> Auger O.D. 6iir I.D. <br /> Drilling Company: <br /> Completion - Stove pipe/c mistie box (circle one) <br /> Driller:_ 1 prrul-1,L.,1j YL, <br /> casing <br /> Consultant height <br /> Geologist" ��—�," L� <br /> �) }�i1J�11}cl�7r ABOVE-GROUND <br /> COYF'LETZN C iRz Y-BOX <br /> SPECIAL PERMIT INFO C-0IMPLET10N <br /> Cirvu nd Surface <br /> Distance to sewer line '�' ��f grout <br /> Domestic well on site - (y n �� <br /> If yes, location and distance <br /> � ft. <br /> O <br /> SAMPLING <br /> t to ttad c <br /> Holding Temperature = <br /> Method ,.� I(� _ ffravgl Pz i <br /> Screening Method <br /> Tracking Sheet - (y/n) <br /> SPOILS <br /> Storage Method 5 67g, p)i/i. Al MA-_T3RIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) _ ��II <br /> Stoo)rag�� tion_SEC.,.I'�1 /`f,�1C / /9-j�,,f/�_ Casing type O /l/L <br /> Blark ft. Screen ft. <br /> GROUTING <br /> Slot size <br /> �/t�/� /7�, Bags cement <br /> Bucy:ets bentonite_ 5-0 ,t x <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method _Surge.Block:_- (_yff- <br /> 30 <br /> Quantity Installed Disc.issed with ge : - (yF / n <br /> Z2 Z'' Type of method <br /> EH 29 29 X 'f 7 ' ) 4� �j /� <br />