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MONITORING WELL INSTALLATION REPORT <br /> CONSTRUCTION <br /> Date: ,- <br /> Premise Address: y �l`"'� Total Depth <br /> Screen Length (from)_ (to) <br /> Well No.: Filter Pack (fron) (to) <br /> Bentonite (from) (to) <br /> w Grout (from) (to) <br /> Inspector. Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling ComMpany: <br /> �� hezgh Fffcas-, ng <br /> Consultant3� <br /> Geologist A!;;VE-GRSD Ct- :STY-B0X <br /> COW l..ETfoP! <br /> cnr_�:d Sul <br /> SPECIAL.PERMIT—INFO- <br /> Distance to ;ewer line _____;-t'• <br /> Domestic wel: on site = (y/ n) n• <br /> If yes, location and distance - ft <br /> — o <br /> — o <br /> lI6%?J <br /> SAMPLING sxicn <br /> Holding Temperature i <br /> Method — <br /> Screenino Method = <br /> Tracking Shce[ - n _ft. — <br /> SP_ O_ILS : <br /> Mn a�nrets/Di;VE(.OPMENT <br /> r <br /> Storage Method <br /> Contamination Noted- (y/ n Casing ripe ft Screen <br /> Storage Location__--­— Blank <br /> Slot size <br /> Bags cement <br /> GR_ O_UTING Buckets ben[onite <br /> Bags sand/gravcl <br /> Depth to water <br /> Filter Pack type/size <br /> Miz Ratios Surge Block: - C Y/Il) <br /> Discussed With geologist: <br /> �stallation Method � � Type of rnetllod <br /> Quantity Installed <br /> EH 29 29 <br />