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MONITORING WELL INSTALLATION REPORT <br /> Date: 3 CONSTRUCTION i <br /> Premise Address: gh A &I Q Pd 9-" Total Depth <br /> W <br /> _ �� Screen Length (from) y (to) S <br /> Well No.: Filter Pack (from) If 3 (to) 'T6, — <br /> Bentonite (from) t( / (to) 143 <br /> Inspector: J (,O*kW Grout (from) v (to) Glr <br /> Drilling rig type PMe `rte✓ <br /> Permit No. Auger O.D. 19`' I.D. <br /> Completion - Stove pipe/ ox circle one) <br /> Drilling Company: <br /> Driller:_ casing <br /> �1�� height <br /> Consultant K <br /> Geologist �/V CQ,kWr-'D eA .. <br /> ABOVE-GROUND <br /> COWLETiON C4-SZ7Y-80X <br /> SPECIAL PERMIT INFO. Gond Surface COMPLE710N <br /> Distance to sewer line (.0L) Grp ' <br /> Domestic well on site - (/�(n ) 1 �J ft• <br /> If yes, location and dist e - � <br /> LOOS � ft. <br /> Lf <br /> a <br /> = m <br /> a <br /> = m <br /> SAMPLING = <br /> Holding TemperaturegravW_ P <br /> ack <br /> Method <br /> Screening Method _ <br /> Tracking Sheet (y/ n ) _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) I/ ^ � <br /> Storage Location Casing type_k_ S lit - q C> <br /> Blank Y S ft. Screen /D ft. <br /> Slot size O-U o' o <br /> GROUTING Bags cement (� <br /> Buckets bentonite / <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size '*4 3 Al <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - 6//In ) <br /> Type of method <br /> EH 29 29 <br />