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MONITORING WELL INSTALLATION REPORT <br /> Date:_ CONSTRUCTION <br /> Premise Address: Total Depth_ 1-9111-4s- <br /> Well <br /> -911o4sWell No.: Screen Length (from)' I �c' f�_(to)�j s <br /> Filter Pack (from) 2 <br /> Inspector: Bentonite' (from) <br /> Grout (from) (to) <br /> Drilling rig type- iM a cI l v�c,J,✓'Y <br /> Permit No. Auger O.D. 4, S" I.D. <br /> Drilling Company: 0CIAlint <br /> mat � �.�;-��� Completion- Stove pipe/christie box (circle one, <br /> �/'� c' � <br /> Drillez: l V''�`� ,:l c V <br /> casing <br /> Consultant <br /> height <br /> GeologistV/'k Az' ��. r)r ._ <br /> AlBO VE-G R CUND <br /> CO t.r'LEf;C N CHR ZTY-BOX <br /> SPECIAL PERmT INFO COMPLE7C)N <br /> C3round Surface <br /> Distance to sewer line Orocrt <br /> Domestic well on site - (y/n) !?� <br /> If yes, Iocation and distance - h, <br /> ft. <br /> SAMPLING = o <br /> ' slotted - — c <br /> sx-�on — <br /> Holding Temperature = <br /> Method <br /> Screening Method - — <br /> Tracking Sheet - (y/n) _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location <br /> Casing type <br /> Blank___I c(tc, �ft. Screen l L ft. <br /> Slot size OP 020 <br /> GROUTING Bags cement 5 7 <br /> Buckets bentonite 2- <br /> Depth to water Bags sand/gravel_ 1-'*l <br /> Mix Ratios Filter Pack type/size It <br /> Installation Method <br /> /_ <br /> ..I <br /> n_)�_ <br /> Quantity nstalled Discussed with geologist: - Cy/n) <br /> EH 29 29 <br /> Type of method_ tvl ,fCi •y'�-}�,,�y <br />