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MONITORING WELL INSTALLATION REPORT <br /> Date: Z, <br /> CONSTRUCTION <br /> Premiss Address• <br /> Total Depth � <br /> Well No.: Screen Length (from) (to) <br /> Filter Pack (from) O <br /> InspInspector. (to)Bentonite (from) ,to) <br /> Grout (from) (to) i <br /> Permit No. Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Company: Completion .Stove pipc/dUiszs box (circle one) <br /> Driller. <br /> casing <br /> Consultant .17 —7m T, <br /> height <br /> Geologist <br /> A$CvE-Grq cUND <br /> SPECIAL, PERMIT INFO. COWL-tT10N CHRM-TY-30x ' <br /> ""-i°-- C3=nd St:iact COMPLEMN <br /> Domestic well on site - (y <br /> Distance to sewer Iine <br /> grout <br /> If yes, location and di ce . <br /> -- ft. ft. <br /> Ste_ +` o <br /> ra tlat'.� <br /> Holding Tem G <br /> pe lure <br /> Method rc <br /> Screening IKethod = GzVelFacckc <br /> Tracking (y/n) Y• <br /> ti. <br /> Storage ?ylethod <br /> Contamination Noted - (y i1 RATE WAI,S WELOPMENT <br /> Storage Location <br /> Casing type J <br /> Blank ft. Screen ` <br /> GR�NGG Slot size I A57 <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios Bags sand/gravel <br /> Installation Method Filter Pack typesize <br /> Quantity Installed Surge Block: - (V 11 ) <br /> Discussedwith n) <br /> EH 29 29 Type of ncdiod Stti[ <br />