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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address:_ /G? 7l7G�t-!�N Total Depth <br /> Screen Length (from)'7q / (to) �,.Well No.: �✓'�Z•9 Filter Pack (from) 7 117 (to);/7ot <br /> Btu (from) 10 S (to) (! . <br /> Inspector: Grout (from) S— (to) d-j <br /> Drilling rig type �►'«D CoP1f¢Y <br /> Permit No. Auger O.D. I.D._ t0 <br /> Completion- Stove pipe/chnstie box (circle one) <br /> Drilling Company: f0r- <br /> Driller: $ ESC /E 79 6-7 <br /> casing <br /> height <br /> Consultant_ /-)A 44121 <br /> Geologist_ <br /> ABOVE-GROUND <br /> COwFLET10N CHRZ Y-80X <br /> COMPLE1l ON <br /> SPECIAL PERMIT INFO. Omand Su lace <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) �3 <br /> If yes, location and distance - h• <br /> 70 ft 6' fi. <br /> SAMPLING iQ° o for <br /> glottad <br /> Holding Temperature <br /> Method 7 <br /> Screening Method _ <br /> Tracking Sheet - (y/n) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location Casing type_#0VC- -s?�lu''tftf SCRE�ti <br /> Blank `tT ft. Screen 'dc** ft. <br /> Slot size 0. 0/0 <br /> GROUTING Bags cement <br /> Buckets bentonite S- <br /> Depth to water Bags sand/gravel .?$ <br /> Mix Ratios Filter Pack type/size: Z /Z <br /> Installation Method Surge Block:_ <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> EH 29 29 Type of method <br />