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MONITORING WELLINSTALLATION REPORT <br /> Date: <br /> CONSTRUCTION <br /> Premise Address: y, d 1� 1Vti�tl-f D!� <br /> Total Depth <br /> Well No.: YlnIij— Screen Length (from) `S <br /> Filter Pack (from) -5 I (to) <br /> Inspector- Bentonite (from) c (to) z� <br /> Grout (froth) <br /> Permit No. Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Company, Completion - Stove pipe/du-isde box (circle one) <br /> Driller. <br /> casing <br /> Consultant — *height <br /> Geologist <br /> ABOVE-GBCtJND <br /> 0CNV LSTCN C 15TY�oX <br /> SPECIAL, PERMIT INFO. C-C&V'L�EnCN <br /> C3nxr�Stxfacs <br /> Distance to sewer line <br /> Domestic well on site - 9rcc�t <br /> (Y/ n ) <br /> If yes, location and dista ft. <br /> ft. It. <br /> J� r <br /> $AMpLING c <br /> c <br /> Holding Temperature s i0c1cn <br /> Methodgnysq pack <br /> - 'r <br /> Screening Method PIN _ <br /> ri• <br /> Tracking Sheet - (y/ n ) w <br /> Storage ?Method <br /> Contamination Noted - ( n MATERIALS EVEI.OPMENT <br /> Storage Location y <br /> Casing type <br /> Blank ft. Screen ft <br /> GR---OLMti'G Slot size <br /> Bags cement <br /> Depth to water �. 1 Buckets bentonite <br /> Mix Ratios Bags sand/gravel <br /> Installation Metho Filter Pack type//size <br /> Quantity Installed Surge Block: - (y <br /> Discussed with geologist: - (y/ n ) <br /> EH 29 29 ! Type of ractliod <br />