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MONITORING WELL INSTALLATION REPORT <br /> Date'_ � (�j(bt-/ <br /> CONCTIOI <br /> Premise Address:_ <br /> Total Depth b S i <br /> Well No.: Screen Len gth (from)_ 6_� Cto) (,.5 <br /> Filter Pack (from) — qk <br /> Inspector' Bentonire (from) CCO) I S <br /> Grout )�s_ (t°) <br /> Permit No. Drillingr' (from) (to) 7- 5 <br /> 9 type <br /> DrillingCom Auger O.D.__� i.D. <br /> Pany ty Completion - Stove pipe/dtrispe bo � <br /> (circle one) <br /> Driller-.�} <br /> Consultant casing <br /> height <br /> Geologist R0 <br /> APCVE-GACUND T <br /> SPECIAL PERMIT INFO. �"N'LST;CN CMS -aox <br /> 'r�-�Cm;nd Suixy <br /> Distance to sewer line �t—EnCN <br /> —T <br /> Domestic well on site - (y/n ) grwi <br /> 140 yes, location and distance - <br /> t 7— <br /> SA_�NG <br /> C <br /> Holdingdorm <br /> Temperature toe cn = <br /> Method — <br /> Screening—Method = Savcl�adt <br /> Tracking Shcet C y/ n ) — <br /> SPOILS <br /> n. <br /> Storage Method <br /> Contamination Noted - (y/n) MATERIALS/DEVEI OpMENT <br /> Storage Location <br /> Casing type V <br /> GRAN-G Slot siz fr e" Screen _fr <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios Bags sand/ <br /> Meth— oa sand/gravel Installation <br /> Filter Pack type/s e a- Iz iz sq�c <br /> Quantity Installed Surge Block: - (y/d <br /> EH 29 29 Discussed with geologist: - ( y/ n ) <br /> Type of method <br />