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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: AI Uo f_< Total Depth <br /> /�w_ y / Screen Length (from)_ &14— (to), _ <br /> Well No.: Filter Pack (from) to 5-- (to) _ <br /> Bentonite (from) („ 3 (to) (0-05- <br /> Inspector: <br /> eSInspector: Grout (from) 0 (to) 65 _ <br /> Drilling rig type e 40 <br /> Permit No. Auger O.D. 5g 'r I <br /> pp �{__ stie (circle one) <br /> Drilling Company: lJ'> Completion - Stove pipe/��� <br /> Driller: 121 <br /> casing <br /> height <br /> Consultant <br /> Geologist Ili 0Y Q'�z <br /> ABOVE-GROUND <br /> COMPLETION CHRZS?Y-BOX <br /> SPECIAL PERMIT INFO. GroundSurfaceCOMPLETION <br /> Distance to sewer line pro�� u 3 <br /> Domestic well on site - 0n ) <br /> If yes, location and distance - f 4 ft. <br /> = m <br /> = m <br /> SAMPLING = o <br /> / slotted — 2 l <br /> Holding Temperature —_ <br /> Method — v&vW Pack <br /> Screening Method = <br /> Tracking Sheet - (y/n ) _ <br /> — ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) _/� '/ <br /> Storage Location Casing type "7j,- `� y f <br /> Blank G--_ft. Screen_ <br /> Slot size_ D moo" <br /> GROUTING Bags cement_(-! <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size >V 3 <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: -6)/ n ) <br /> EH 29 29 Type of method <br />