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MONITORING WELL INSTALLATION REPORT <br /> Date: `I b� CONSTRUCTION <br /> Premise Address:1:;,9k C, w ` 5 U-)'\ Total Depth l <br /> Screen Length (from) L:56 (to) <br /> Well No.: Filter Pack (from) /5 6 (to) <br /> Bentonite (from) 13' (to) <br /> � <br /> Inspector: Grout (from (to) <br /> Drilling rig type l o ✓� <br /> Permit No. Auger O.D. <br /> Completion - Stove pip c stile box (c cle one) <br /> Drilling Company: �� <br /> Driller: v casing <br /> height <br /> Consultant � r(� T <br /> GeologistA4q� 7//, <br /> T <br /> ABOVE-GROUND <br /> COMPLEfCN CHRZ Y-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground gur{ws <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n ) <br /> If yes, location and distance - <br /> �ft. ft. <br /> _ a <br /> C <br /> SAMPLING <br /> slotted — d <br /> secton f <br /> Holding Temperature <br /> Method —_ g"vW pack <br /> Screening Method <br /> Tracking Sheet - (y/n ) 4.- <br /> ... S bn. = /-s n- <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) r, ' i <br /> Storage Location Casing type V c__ <br /> Blank /�Z ft. Screen ft. <br /> Slot size V Y <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />