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.AONITORING WELL INSTALLATION REP <br /> Q <br /> G <br /> 2D 1 <br /> Date:T f CONSTRUCTION �6 <br /> Premise Address: FA (001) Le v C Total DepthJ " i t * 1v <br /> Screen Length (from) (to) <br /> Well No. : Filter Pack (from) (to) <br /> i Bentonite (from) (to) <br /> Inspector: R2i±: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> &,� rye f ` 1 Completion - Stove pipe/christie box (circle one) <br />' Drilling Company: [Af' � �`yy�'u,••� <br /> Driller: <br /> casing <br /> he ±ght <br /> Consultant (& fL I T774 <br /> Geologist LG.wt <br /> ABCVE-GACUND Ci4ilSTY BCX <br /> CaMPLETbN COMPLEnCN <br /> SPECIAL PERMIT INFO. Grwrd Sumacs <br /> Distance to sewer line IA. grout <br /> Domestic well on site - ( y ) <br /> If yes, location and distance - fto <br /> ft. <br /> ft. <br /> ISAMPLIN soricn mperature <br /> ack <br /> FMethod heet - ( y / n ) <br /> ft. _ = fte <br /> SPOILS <br /> Storage Method Dp!✓Ux3 MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y /( 0 rr�JuL S �o <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> t1 Buckets bentonite <br /> Depth to water ,,LID Bags sand/gravel <br /> Mix Ratios _ wk e t Filter Pack type/size <br /> Installation Method +moi V I Surge Block: - ( y / n ) <br /> Quantity Installed Discussed with geologist: - ( y / n ) <br /> Type of method <br /> EH 29 29 <br />