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MONITORING WELL INSTALLATION REPORT <br /> Date: // CONSTRUCTION <br /> Premise Address: :KIK IcArn RaJ Total Depth S2' <br /> Screen Length (from)43r_(to� <br /> Well No.: VK Lt) — Filter Pack (from)_ 14 —(to) <br /> ` Benronite (from) <br /> inspector. I �14 AAA rC1 r.-. . Grout (from) _(to) <br /> Drilling rig type <br /> Permit No. n Z C> �K -,� 77- Auger O.D. l n' � I.D. <br /> Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling Company: /10c t a <br /> Driller: t/ �t S casing <br /> �t p height <br /> Consultant [ _CA AM An I C', <br /> Geologist <br /> A CVE-Gr7CUND ;,}�lST1'-20X <br /> COh4'Lr�ffON •OMPLEY ICN <br /> SPECIAL PERMIT INFO. G=nd Suef <br /> Distance to sewer line 1prcn <br /> Domestic well on site • ( y/ n ) y O. ft. <br /> If yes, location and distance - <br /> zft. <br /> = c <br /> SAMPLING �Iorod <br /> cn <br /> tae <br /> ft. <br /> Holding Temperature peva PaCK <br /> Method ro 't <br /> Screening Method P t D Yr <br /> Tracking Sheet n ) — <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y7 n ) <br /> Storage Location_ S���• Casing type <br /> Blank ft. Screen <br /> Slot size , c' t t5 <br /> GROUTING Bags cement � I 'Z- <br /> Buckets <br /> Buckets bentonite l <br /> Depth water I Bags s avcl <br /> Mix Ratios 3 6aso�Q,w_��t _��,�Q z.© Filter Packack rytype/size 2 h i o fw. Sc:�� <br /> Installation Me�tho �L mbE Surge Block: - ( y,(154 <br /> QuantiryInsralledN l sem' tj, mune Discussed with geologist: - ( y/(�iv) <br /> Type of method <br /> EH 29 29 <br />