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-- MONITORING WELL INSTALLATION REPORT <br /> Date: l `� CONS' RUC 1ON <br /> rr t !`,! 521 <br /> Premise Address: � � � t VL���Y _ _- ` Total Depth <br /> ' Screen Length (from) 5 2 (to) 3 z <br /> Well No.: Fite: Pack (from) 5-2 (to) 30 <br /> Bemmnite (from) 30 (to)Z <br /> Inspector: JC UV Grout (from) (to) <br /> Drilling rig type 13* <br /> Permit No. Aaiger O-D. S Z I.D. `F 14) Compietion-Stove pipe/caristie box (circle one) <br /> Drilling Compenr. rte `Zou/� <br /> Driller: /la t C kL t'►-c� �jY 2 cas 3:1g <br /> he_ghz <br /> Consultant Y 0.2 Gt�1 T I <br /> h0. <br /> Geologist, rckce <br /> ASCVE-GACVNO CI.-SIS <br /> CCWPI—=i ICN =+AP'___T iCN <br /> SPECiA.L PERT INFO. <br /> 'V 2�_ <br /> Distance to sewer line j <br /> Domestic well on site - (y <br /> if yes, location and distance - - 30 <br /> 3 1 _ 30 <br /> ;z <br /> SLING —.td <br /> Holding Temperature <br /> Method (G CSC?;gni I"�f rd7RPaCK <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) = Z <br /> SPOMS <br /> Storage IViethod MAT ER LAIS/DEVEL0PN ENi <br /> Contamination Noted - ( / ) <br /> Storage Locationf� S! _ Casing type <br /> Black so fz Sc-eeri 20 f <br /> Slot size 0 <br /> GROUTING Sags cement <br /> r Buckets bentonite • T 5 <br /> Depth to water Bags sand/g.- <br /> Mix Ratios Fater?acct typesize Zn <br /> Installation Method Surge BIock: - (yQuantity Installed Disc*_ssed with ge -on ) <br /> Type of method <br /> E.-I 29 29 <br /> P vR r `w <br />