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MONITORING WELL INSTALLATION REPORT <br /> Date:_ 1 Z R /I CONSTRUCTION <br /> Premise Address:_ 4 3 Total Depth SL <br /> Well No.: J\ Screen Length (from)------q- <br /> - Filter Pack (from)1— Z ((to) <br /> Inspector; <br /> Bentonite (from) 3 !j (to) _ <br /> _ I�, .� Grout (from), 9� _(to)_=T <br /> Permit No._ <br /> O Drilling ng type <br /> Auger O.D. I.D. <br /> Drilling Company: 1 <br /> Completion - Stove pipe/christie box (circle one) <br /> Driller:__ 1n casing <br /> Consultant /�� y(�,_, <br /> height <br /> Geologist_ -r :k1 <br /> ABOVE-GROUND <br /> __—...--- _..._ COMPLETION CHASTY-80X <br /> SPECIAL PERMIT INFO - SON <br /> Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ <br /> If yes, location and di ce - ft <br /> — o <br /> SAMPLING = <br /> No Ow,oNt,�� L G 46?" slotted <br /> _ c <br /> 00 - taxon — <br /> Holding Temperature — <br /> Method = gravel Pads <br /> Screenin ethod — <br /> Tr g Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method g!ja yy(tu,(.i:T MATERIALS/DEVELOPMENT <br /> Contamination Noted - y/ n ) Z (QVC <br /> Storage Location a ,, sif. Casing typGl;c�'5dm. tam., <br /> Blank Y,Z.. ft. Screen <br /> Slot size Ao f�.Al iaj <br /> GROUTING Bags cement <br /> Depth to water Buckets biq�6e <br /> Bags sand/gravel <br /> Mix Ratios o Filter Pack typesize Z <br /> Installation Method nanw.. �.! Surge Block: - (y/n <br /> Quantity Installed_ti rvo I ,�� Discussed with geo gist•. -(G?/ n ) <br /> EH 29 29 Type of method <br />