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MONITORING WELL INSTALLATION REPORT <br /> Date: 1 I1 j h s <br /> CONSTRUCTION <br /> Premise Address: 7617 . <br /> Total Depth C/ <br /> Well No.: A tA)-j-_j Screen Length (from) J r (to)—_ <br /> Filter Pack (frcim) r <br /> P J, `�ojo . ►1ln Bentonite �'�_—(`o'—� - <br /> Ins ector: (from) Y Y <br /> Grout -(to) _ <br /> (from) <br /> Permit No._ !:K "7 i 2_3 -7 Drilling rig type�/�,r} <br /> Auger O.D.Iff' I.D. <br /> Drilling Company: r �� -� /�� Completion - Stove pipe/christie box (circle one) <br /> Driller: <br /> casing <br /> Consultant <br /> ��. �-� � C, � height <br /> Geologist_ <br /> A50VE-GROUND <br /> SPECIAL PERMIT INFO. C WFLET;0N CNRS',Y-6px <br /> COMPLETON <br /> ----� <br /> Ground Suiace �---� <br /> Distance to sewer line <br /> Domestic well on site - (Y/n ) Groin <br /> If yes, location and distance - $ <br /> ft. <br /> SAMPLING = r <br /> t to tted <br /> •r: c <br /> Holding Temperature Bacon = <br /> Method <br /> Screening Method — v"'q�Pack <br /> Tracking Sheet - (y/n ) <br /> 60 - <br /> SPOILS "— <br /> ft. <br /> Storage Method <br /> Contamination Noted - (y/n ) MATERIALS/DEVELOPMENT <br /> Storage Location <br /> ---- Casing type of T�fz `i0 fIlG <br /> Blank _ Screen <br /> Slot <br /> GROUTING size (3 0 <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios - Bags sand/gravel <br /> Installation Method Filter Pack type/size _ <br /> Quantity Installed --- Surge Block: - (y/n ) <br /> Discussed with geologist: - (y/ n ) <br /> EH 29 29 Type of method <br />