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MONITORING WELL INSTALLATION REPORT <br /> Date:_ _ �/l 3 J D CONSTRUCTION <br /> Premise Address:_ Total Depth <br /> Screen Length (from) 25 (to) 5 <br /> Well No.: <br /> k-`''" ' �, S cg i tc� Filter Pack (from) 25-- (to) 3 <br /> � � / Bentonite (from) 3 (to) d-- <br /> Inspector: Grout (from ?_ -(to) <br /> � <br /> Drilling rig type S <br /> Permit No. .S?Z�?/ Auger O.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant. A <br /> Geologist 7 <br /> ABOVE-GROUND <br /> COMPLETION ic4-nZiTy <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surlaca <br /> Distance to sewer line afout <br /> Domestic well on site - (y/ n ) ft <br /> If yes, location and distance - <br /> �ft. ft. <br /> = m <br /> q <br /> C <br /> SAMPLING <br /> slatted � <br /> Holding Temperature y L <br /> Method ��i- .-�• �"�P <br /> Screening Method =_ <br /> Tracking Sheet - (y/ n ) — <br /> 2 ft. _ fid- ft. <br /> SPOILS n Z <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> It <br /> Storage Location Casing type 67 PC4 <br /> Blank ' ' ft. Screen 2-o ft. <br /> Slot size /7-02-0 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water J' ��/ Bags sand/gravel 4 / /'7 <br /> Mix Ratios c Filter Pack type/size <br /> Installation Method Surge Block: - (y o ogist:n�j <br /> Quantity Installed G S Discussed with ge (�/ n ) <br /> Type of method <br /> EH 29 29 <br />