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MONITORING WELL INSTALLATION REPORT <br /> Date:_ 61 ( -6(p Z CONSTRUCTION <br /> Premise Address: 1 -2,G S• p,,..7�-r P <br /> e th 33 <br /> � Total D <br /> Screen Length (from) (to) <br /> Well No.: IM(� '1 �� -�-c� L{tilCL( ,� Q�o,uja�. Filter Pack (from) ( � (to)— _ <br /> U�' O Bentonite (from) ) �( ' (to)-- I,� <br /> Inspector. 11.�,�,.�.._ ` Grout (from) �o (to)� <br /> Permit No. O 1 Drilling rig type Auger O.D. I.D. <br /> Drilling Company:_ Co�,�, .Q e Completion - Stove pipe/christie box (circle one) <br /> Driller: <br /> casing <br /> height <br /> Consultant_ 5(�_7 e-, � <br /> Geologist C 1. cdr <br /> ,• T <br /> APCVE-GRMND <br /> COMVL_`rCN CW�tSTY 30X <br /> SPECIAL PERMIT INFO, COMPL-°TICN <br /> C3round Stsfacs <br /> Distance to server line orad <br /> Domestic well on site - (y/n ) , <br /> If yes, location and distance - _.7 L►_.ft. <br /> SAMPLING —' c <br /> •lord <br /> Holding Temperature :ocicn <br /> MethodVIV1W Pack <br /> _~ <br /> Screening Method <br /> Tracking Sheet - (y/ n ) _ <br /> SPOILS <br /> Storage Method_ 1�IATERIALS/DEVEI OPMENT <br /> Contamination Noted - (y/n ) <br /> Storage Location <br /> Casing type Z 1 1 P L` <br /> Blank- ( S ft. Screen_ <br /> GR_OIMNIG Slot size O ZD <br /> Bags cement_ 3 <br /> Depth to water Buckets bentonite . <br /> Mix Ratios _ A N _ Bags sand/gravel ti,� ,b� <br /> F �/-(�� Filter Pack type/size <br /> Installation Method ,n--n,,,.. <br /> Quantity Installed Surge Block: - (y/01 <br /> Discussed with geologist: - (y/9) <br /> EH 29 29 Type of method <br />