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MONITORING WELL INSTALLATION REPORT <br /> J <br /> Date: z 03 CONSTRUCTION <br /> Premise Address: Total Depth 3 p <br /> l �v IM SIC LAJe 7_ C �'1 q�iY1� Screen Len <br /> Well No.: •"4 Length (from) I (to) <br /> MIA `�(Z Filter Pack (from)_ (to) <br /> Lw.�ol�s+� Bentonite (from) (to) <br /> Inspector. o, , Grout (from) <br /> —(to)�_ <br /> Permit No. Drilling rig type_( . <br /> _ �,��5,(� -� Auger O.D. I.D. <br /> Drilling Company, C Completion- Stove pipe/chri.sde box (circle one) <br /> �-��r� <br /> Driller._ j <br /> 4 <br /> casing <br /> height <br /> Consultant if , <br /> Geologist_ <br /> APCVE-GACCND <br /> C0 NV LFTION C_�GJS'TY_aox <br /> SPECIAL PERMIT INFO. COMPUTICN <br /> Cxcund Stslacs <br /> Distance to sewer line oralt <br /> Domestic well on site - FY/ n ) <br /> I'yes, location and distance <br /> _ .it• ft. <br /> — _ a <br /> SANG r <br /> tlora'd —" c <br /> Holding Temperature i°`'`^ <br /> Method <br /> Screening Method 01 <br /> Tracking Sheet - (y/n ) _ <br /> SPp1IS -3 0 .ff. ft. <br /> Storage Method <br /> Contamination Noted - (y/n ) MATERIALS/DEVE[OPMENT <br /> Storage Location <br /> Casing type <br /> Blank ft. Screen <br /> GRANGG Slot size <br /> Bags cement - <br /> Depth to water Buckets bentonite - - <br /> Mix Ratios Bags sand/gravel <br /> Installation Method' Filter Pack type/size <br /> Quantity Installed Surge Block: - (y/;i1 ) <br /> ' Discussed with geologist: • (y/ n,) <br /> EH 29 29 Type of method <br /> 0 • <br />