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MONITORING WELL INSTALLATION REPORT <br /> Date: Z CONSTRUCTION <br /> Premise Address: co N_ //wy Total Depth ?� <br /> Screen Length (from) Sy (to) <br /> Well No.: SUS / Filter Pack (from) S (to) <br /> Inspector: J• `10nKU01 S up(from) So (to) 5f <br /> Grout (from) (to)aa <br /> � Drilling rig type <br /> Permit No. L S G 80 AugerO.D. I.D. <br /> tove pip o (circle one) <br /> Drilling Company:_ Completion(li¢gyp <br /> Driller: lt*R 5#941 i?% casing <br /> height <br /> Consultant_ 19A(7,1jJ/5 <br /> Geologist Sl k J'Hil146it <br /> ABOVE-GROUND <br /> COMPLETION C♦iRIM-BOX <br /> SPECIAL PERMIT INFO. COMPLETION <br /> Ground Surface <br /> Distance to sewer line orout <br /> Domestic well on site - (y/n 5-0 <br /> If yes, location and distance _tt. <br /> 3 y tt. s z ft. <br /> r <br /> — o <br /> SAMPLING o <br /> slotted c <br /> Holding Temperature &#cdon B <br /> Method__ MR'rgr LE�cs 't = Qrnreipxk <br /> Screening Method r/ID <br /> Tracking Sheet - (y/n) <br /> SPOILS tt. <br /> Storage Method D Pum MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Locationc)SLS (7< Casing type 5614<Dw.t q& PVC <br /> Blank $�ft. Screen /S ft, <br /> GROUTING Slot size <br /> Bags cement <br /> Depth to water 7v Buckets i <br /> Ee cs�n ? B/ecs <br /> Mix Ratios of / 3a �sS Bags sand/gravel 15 <br /> Installation Method_ rgj Filter Pack type/size, Z/G -r^lb <br /> Quantity Installed Surge Block: - (y/QD <br /> Discussed with geolgis . - (y/ ) <br /> EH 29 29 Type of method <br />