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MONITORING WELL INSTALLATION REPORT <br /> Date: c,__i 2 CC7 CONSTRUCTION <br /> Premise Address:_ G I n 0 t\) �t �7 Total Depth c J <br /> Screen Length (from) r{, t (to) sl <br /> Well No.: {M (A1 —Z Filter Pack (from) � <br /> Bentonite (from) t(�?_(to) r�� <br /> Inspector. �� r Grout (from) cp (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company. <br /> Completion - Stove pipe/du-istie box (circle one) <br /> -���a - <br /> Driller: L)-rA%&A casing <br /> T height <br /> Consultant r r7 t <br /> nq <br /> —Q Geologist rAn n M VT <br /> ABOVE-GROUND C}4itSTY30X <br /> OONVLETION cOMPLcTICN <br /> SPECIAL PERMIT INFO. Grourd Su ire <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - 9 D ft. <br /> 3 ft. <br /> a <br /> _= m <br /> = o <br /> SAMPLING — <br /> slonod <br /> - — <br /> Holding Temsocicn <br /> perature f c <br /> Method ! lnc or w f ( 1 t2- i <br /> Screening Method _T _ <br /> Tracking Sheet - ( y/ n ) <br /> ft. ft. <br /> SPOILS <br /> Storage MethodeM V f r ( t C MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ <br /> Storage Location s Casing type eve <br /> Blank t . ' ft Screen 2,C-) ft. <br /> Slot size 402,0 <br /> GROUTING Bags cement <br /> Depth to watBuckets bentonite i <br /> er mac' Bags sand/gravel <br /> Mix Ratios -5 - c t,t Filter Pack type/size 2 <br /> Installation Metho a Surge Block: - ( y/ n ) <br /> Quantity Installed V Discussed with geologist: - (y/ n) <br /> EH 29 29 Type of method <br />