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MONITORING WELL INSTALLATION REPORT <br /> Date:_ I ;L I D CONST RUCTION <br /> Premise Address. (Z ( I p _ <br /> �„---_ y�K rs� � (�/� Total Depth_ s\w..e <br /> Screen Length (fro 3-t (to)_ <br /> Well No.: hn(A1 Filter Pack (from)_ � 1- <br /> r. to <br /> Bentonite (from)_�5E.S' (to) T <br /> Inspecto `�� Grour (from) (to)_ X45 <br /> -Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> p Completion - Stove pipe/christie box (circle one) <br /> Drilling Company:_ Lg�� � <br /> Driller':_ _ casing <br /> height <br /> Consultant `V <br /> Geologist �orUy4�s TCahn ,�� <br /> • � A-AYE-GRCUND <br /> CCWPLETf ON C}- :STY 3oX <br /> SPECIAL PERMIT INFO. Gird Su acv CCkA?Lc-T1CN <br /> Distance to sewer line <br /> Domestic well on site - /n) 33•S It <br /> If yes, location and tante - <br /> ft. <br /> �h• <br /> 4 - <br /> M <br /> C <br /> SAMPLING — <br /> ifor:a.J — C <br /> Holding Temperature Q1n t ci\ <br /> Method_ <br /> Screening Method — <br /> Tracking Sheet - n ) <br /> L1 tt. = ft. <br /> SPOILS <br /> Storage Method MATE tF IALS/D&E[ dk3571 <br /> Contamination Noted - / n ) <br /> Storage Location Casing type a PJ< <br /> Blank 10 ft. Screen <br /> Slot size d ZfJ <br /> GROUTING Bags cement <br /> Buck:ts bentonite <br /> Depth to tvater NBags sand/gravel <br /> Mix Ratios Filter Pack type/size a t ZZ <br /> installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed vrith geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29. <br />