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MONITORING WELL INSTALLATION REPORT <br /> Date:__ 2 2 z p 2 CONSTRUCTION <br /> Premise Address: Total Depth so <br /> ��/ L� 6 Screen Length (from) (� <br /> f Filter Pack (from)—�4 t (to) <br /> Well No.: A I <br /> Inspector (�,n� �oN , Bentonite (from) �4 ` (to)-- <br /> Grout (from) (to) <br /> Permit No._ j :7 'I Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Company:_ 1A ArFe �.ol)� Completion - Stove pipe/ tie bo (circle one) <br /> Driller: 1 � MA l (- „ l <br /> casing <br /> � � <br /> Consultant_ (110CAA tn70tT�V1, he_ght <br /> Geologist_ LoLe <br /> ABCVE-Gr'iCUND <br /> C ON-FLE DON C41i1SI`(-aoX ' <br /> SPECIAL PERMIT INFO. COMPLET CN <br /> Cara;rd Strfact <br /> Distance tosewer lin grout <br /> Domestic well o tie�—// n ) <br /> If yes, ]oca ' n and distance - ft <br /> ft. ft- <br /> SAMPLING <br /> doral — c <br /> e suc�cn = <br /> Method_ (_ " fie,r-nr,>_n_2.� 0 nf� / <br /> Screening Method L r , '— <br /> Teaclg-S}tet <br /> SPOILS <br /> Storage Method �; <br /> Contamination Noted - y n MATE RIALS/DEVE[OPMENT <br /> }--bn 4h <br /> Storage Location 6'� I rVe <br /> Casing type_ � <br /> Blank— �h Screen <br /> GROUTING Slot size !2 <br /> Bags cement <br /> Depth to water Buckets bentonite l %s <br /> Mix Ratios 132g sats gravel ry lr <br /> Installation Method Filter Pack type��,�,)�e <br /> Quantity Installed Surge Block: - y rt ) <br /> Discussed with geologist: - y�/ n ) <br /> EH 29 29 Type of mediod jcMAC r � L <br />