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MONITORING WELL INSTALLATION REPORT <br /> Date:_ I CONSTRUCTION <br /> Premise Address: �(Z 1 h ). ` Total Depth 5' l <br /> Well No.: Screen Length (from) 1.O (to) - _ <br /> Filter Pack (from) 4r ` (to) 1 e <br /> Inspector- j1 s S Bentonite (from) (to)__ --- — <br /> �A nh r n� �' d <br /> Grout (from)_ -0 (to) i-- _ <br /> Permit No. Drilling rig type <br /> Auger O.D. <br /> Drilling company- Completion - Stove pipe lristie box (circle one) <br /> Driller. A <br /> casing <br /> Consultant height <br /> Geologist <br /> AP,OVE-GROUND <br /> CO W Lr=TION C4 -aOX <br /> SPECIAL PERMIT INFO. COMPt.�TiCN <br /> Gmund SLzixs <br /> Distance to ;ewer line <br /> Domestic well on site - Gran <br /> (y/ n <br /> If yes, location and dista <br /> ' ft. <br /> ( k-1- <br /> 0 <br /> r <br /> SA—MPLING __ c <br /> •lora. :.� — c <br /> Holding Temperature secicn <br /> Method — <br /> = paval F <br /> Screenin;Method _ <br /> Tracking Shcet - (y/ n) <br /> Storage Method_S S�yn <br /> pjj��t, <br /> Contaminarion Noted - ( MATERIALS/DEVE[OPMENT <br /> Storage Locar'on S'#o �% <br /> Casing type <br /> Blank An fL Screen_ �. <br /> GR_ OUTI\G Slot size •b'LO <br /> Bags cement �t, <br /> Depth to water Buckets bentonite_t 3 <br /> Mix Ratios -, Bags sand/gravel Z z <br /> Installation Metho Filter Pack type/size �i Z <br /> Quantity Installed Surge Block: - (y/ Il <br /> Discussed with geologist: - (y <br /> EH 29 29 Type of method <br />