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MONITORING WELL INSTALLATION REPORT <br /> Date:_ /s/� 3 CONSTRUCTION <br /> Premise Address:_ 16 077 gr�,��d.v R�•4r] Total Depth /r0 <br /> w3 Z_��O Screen Length (from)' /Z o (to) /5`0 <br /> Well No.: Filtei Pack (from) I i S' <br /> Bentonite" (from) Its- <br /> Inspector: (to) L S <br /> Grout (from) eD (to) ur <br /> Drilling rig type �-p <br /> Permit No. Auger O.D. 10 " I.D. <br /> �Rf(6 Completion- Stove pipe/ 'stie o� (circle one) <br /> Drilling Company: DR/<<l..vG <br /> Driller:_ /Q,v'fL S.4 z z4,f <br /> casing <br /> height <br /> Consultant /4RC.¢n!5 ' <br /> Geologist /K <br /> ABOVE-GROUND <br /> cowLE ION CMM-BOX <br /> SPECIAL PERMIT INFO. COMPLE ON <br /> C3rcund Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) ��f �• <br /> If yes, location and distance - <br /> 20 I t 8 ft. <br /> ft. <br /> ' O <br /> SAMPLING — o <br /> Ilatted = <br /> Holding Temperature = <br /> Method — V'W Pack <br /> Screening Method = <br /> Tracking Sheet - (y/n) <br /> Ifo <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location Casing type fl-" Sc H Ifo <br /> Blank I z o ft. Screen 2.c> ft. <br /> Slot size_ O <br /> GROUTING Bags cement <br /> Buckets bentonite 2_ S <br /> Depth to water Bags sand/gravel 2 6 <br /> Mix Ratios Filter Pack type/size 14 Z i L <br /> Installation Method _ _ Block: <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> EH 29 29 Type of method <br />