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MONITORING WELL INSTALLATION REPORT <br /> l <br /> Date: I9Z CONSTRUCTION <br /> dc <br /> Premise Address : Total Depth � ' / <br /> Screen Length (from) /O (to) z <br /> Well No: Lt) 2 Filter Pack (from) 9 (to) 2 f <br /> C ; J Bentonite (from) fr (to) 9 <br /> Inspector, A �/ Grout (from) / (to) as <br /> Drilling rig type <br /> Permit No. Auger O.D. 119 FI.D. 6 <br /> Completion - Stove pipe/duistie box (circle one) <br /> Drilling Company: f� <br /> Driller: :� � �a/ casing <br /> height <br /> Consultant ��/ v - <br /> J J . <br /> Geologist ✓� / re <br /> ABOVE-GROUND chASrr Sox <br /> W Ar' LEifON COVAPLc-TICN <br /> SPECIAL PERMIT INFO. G=rd S <br /> OF <br /> Distance to sewer line ara t <br /> Domestic well on site - ( y / n ) It. <br /> If yes, location and distance - ft <br /> h. <br /> AMP-LING <br /> IQC7Cn — <br /> Holding Temperature _ _ p cwt paoc <br /> Method <br /> Screening Method _ <br /> Tracking Sheet - ( y / n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVEI.OPMENT <br /> Contamination Noted • ( y / n ) <br /> Storage Location CasingtypeBlank fc Screen <br /> ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonire <br /> Depth to water Bags sands/ avel T <br /> Mix Ratios Filter Pack type/size <br /> drtstallation Method Surge Block: - ( y / n ) <br /> Quantity Installed Discussed vAth geologist: - ( y / n ) <br /> Type of method <br /> EH 29 29 <br /> rf P (v1 NONv_ �k CLa..�f 14e 4 .� <br />