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MONITORING WELL INSTALLATION REPORT <br /> Date:_ 7131 14 CONSTRUCTION <br /> Premise Address: C % l Y k + - Total Depth �� I <br /> M _ ' ,� Screen Length (from) <br /> om �p <br /> Well No.: -�---( ) <br /> Filter Pack (from) --R� _(to) _ <br /> Inspector: Bentonite (from) (p5' <br /> Grout (from)_ (off' ' <br /> (to) a <br /> Permit No. <br /> S (0 9 O N I <br /> Drilling rig type__I,c 1 l v►_ 5 ip m <br /> Auger O.D._ '� I.D. y s � <br /> Drilling Company: Completion- Stove pipe/chnstie box (circle one) <br /> n,l(. <br /> Driller: ,P casing <br /> �/► <br /> Consultant `/� S height <br /> Geologist_ Lzae-& <br /> ABOVE-GROUND <br /> COMPLETION CHRISiY-80X <br /> SPECIAL PERMIT INFO COMPLETION <br /> Ground Suriac9 <br /> 0� <br /> Distance to sewer line groat <br /> Domestic well on site - (y/n) A. w+ <br /> If yes, location and distance - 1 <br /> 4 <br /> sumo( . <br /> SAMPLING <br /> 0 <br /> slotted — c <br /> sa-�On ^= <br /> Holding Temperature <br /> Method b r a55 i nay►<. i�� = "va Pack <br /> Screening Method <br /> Tracking Sheet (y/n) _ <br /> SPOILS <br /> Storage Method 951j FAQ- ulw uryLS L2� MATERIALS/DEVELOPMENT <br /> Contamination Note— d - <br /> Storage Location A C VU A AMCasing type PV G –Sly,ui Oc 10 <br /> Blank 2'5 ft. Screen S ft- <br /> Slot size 0. [110 i aci 1 <br /> GROL►TlNG Bags cement <br /> Buckets bentonite <br /> Depth to water_ Bags sand/gravel <br /> Mix Ratios Filter Pack type/sizeAM MA __ d *: <br /> Installation Method_ _________. Surge Block:_(_y_/n_) <br /> Quantity Installed Discussed with geologist: - (y/n) <br /> EH 29 29 Type of method <br />