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MON TORING WELL INSTALLATION REPOR* <br /> Date: ( � t O CONSTRUCTION <br /> Premise Address: 41,-�J \41S't'VW✓ C Total Depth A-V <br /> Screen Length (from) 1j-�> (to) <br /> Well No.: Filter Pack (from) I R (to) 4-4_ <br /> I . ( \ Bentonite (from) (to)--L3 <br /> Inspector: S2w'M_ lJ:cp< Grout (from) (to) <br /> �� 5 M p`7 Drilling rig type �n <br /> Permit No. o I Auger O.D. I.D. <br /> Drilling Company: <br /> Completion - Stove pipe/christie box (circle one) <br /> 1 S�f_�•W�/� _ <br /> Driller: (/�n �7br>7, SOS casing <br /> /�'� _ height <br /> Consultant 1 r , <br /> Geologist t-> aa TCMnn� / T <br /> ABOVE-GROUND ii <br /> COMPLETION CHAIST 4= <br /> SPECIAL PERMIT INFO. Ground SurfCOMPLEn <br /> Distance to sewer line - grout <br /> Domestic well on site - (y/ n ) S n. <br /> If yes, location and distance - <br /> = m . <br /> = e <br /> = m <br /> SAMPLING = <br /> dattud � <br /> Holding Tem ature <br /> Method — qMW Pack <br /> Screening Method : <br /> Tracking Sheet - (y/ n) s' — <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT Cu5 <br /> Contamination Noted - (y/n ) 9- y <br /> Storage Location , Casing type Pig, 5 `t <br /> Blank ft. Screen ft. <br /> Slot size 42,0'5Z-,> <br /> GROUTING Bags cement i's <br /> Buckets bentonite '2, §-'L <br /> Depth <br /> §-'L <br /> Depth to water I� `S� �ags sand/gravel �gxw <br /> Mix Ratios L Filter Pack type/size &I <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />