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MONITORING WELL INSTALLATION REPORT P ooq O f d-- <br /> CONSTRUCTION <br /> Date: <br /> l W Al Total Depth to 83 <br /> Premise Address:r � Screen Length (from) °t3�( ) <br /> 6�oW Filter Pack (from) -TA, —(to) ` <br /> Well No: entonite (from) "t — --(to) t <br /> Grout (from) ly—(to) 5 'L <br /> Lln �7i�a C�t Drilling rig <br /> Inspector. <br /> Auger O.D. I.D. <br /> __� <br /> permit No. l Completion - Stove pipe/dlnstie box (circle one) <br /> Drilling Company: <br /> LaA <br /> r-�-( casing <br /> Driller: � � height <br /> Consultant <br /> Geologist f1 r` S r > i ABOVE-GRCUND C4. :M-Box <br /> CaypLETION cv't P�-TION <br /> q4l„ 4 Cx=rd Suir* <br /> SPECIAL PERMIT INFO. gran <br /> r <br /> Distance to sewer line 13 ft. <br /> Domestic well on site = (y/ n) i�v^ �'-�! ft. <br /> ri <br /> If yes, location and distance - <br /> a <br /> SAMPLING soden <br /> -_ ¢-avot pads <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Trackg cet Sh - (Y/ n) _ ft' <br /> intt. <br /> SPOILS Rea-E Ar S/DEVELOPMENC <br /> Storage Method `^ <br /> Contamination Noted - (Y/ n) Cuing type V (' <br /> storage Location <br /> Blank- — Screen_ <br /> Slot size <br /> Bags cement t a <br /> GROUTING Buckets bentonite <br /> Bags sand/gravcl <br /> Depth to water Filter Pack type/size <br /> Miz Ratios Surge Block: - (Y/ t1) <br /> dltstalladon Method Discussed With geologist: - (y/ n) <br /> Quantity Installed Type of mcdlod <br /> EH 29 29 <br />