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j MONITORING WELL INSTALLATION REPORT <br />,I <br /> Date:- <br /> CONS RU <br /> Premise Address:Zofs -- <br /> me q <br /> Total Depth �� 1 <br /> Well No.: Hyl W_ 5— Screen Length (from �� <br /> Filter Pack )— =t—C[o)� <br /> Inspector: <br /> (from) (to) p) <br /> lr t men Bentonite (from)_ kc i <br /> . Grout (fro <br /> m <br />� Permit No. 4 p 2-2-9 (� .Drilling rig type )�—(to) <br /> Auger O.D. <br /> g <br /> DrillinCompany p I.D. <br /> JA p��}g Completion -Stove PIPe/dui debo <br /> (circle one) <br /> Driller. vp <br /> Consultant_ casing <br /> [ 1 <br /> � height <br /> Geologist 71 � \ <br /> ABOVE-GRCUND - <br /> SPECIAL PERMIT INFO. OOkPL_`TION C7+ Z-yaox <br /> Cvund Staixti CCMPLmCN <br /> Distance to sewer line ! — <br /> Domestic well on site - C Y/n) <br /> if yes, location and dicta ora t <br /> SAMPLING = <br /> 4 <br /> Holding Tempe a doted <br /> Method mre sacicn — B <br /> Screenir v�etnoo �� _ — �vd <br /> F�dr <br /> Tracking — <br /> g Shcet n ) <br /> SPS B. __ `:- — <br /> b R. <br /> Storage Method <br /> Contamination Noted - MATERi <br /> Storage Locarion�n S a �jLS/p 1 OPMENT <br /> Casing type, 21 V <br /> ~ (� <br /> GROUTING Blan ' It�C_ fL Screen <br /> Slot size ,pip <br /> Depth to water <br /> Dags cement <br /> ' w s5- ' Buckets bentonite <br /> Mix Ratios <br /> Installation Method Bags sand/gravel <br /> ac .., <br /> Filter Pk <br /> QuantityInstalled tYPe/stze k <br /> Surge Block: n ) <br /> EH 29 29 Discussed with geologist: - C y <br /> Type ormediod <br /> y <br />