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MONITORING WELL,INSI'ALLATTON REPORT <br /> Date: Z 2.0 p 4 <br /> N_ <br /> Premise Address: l�y � t7 p �I ,-( CONSTRUCTION <br /> Well No.: Total Depth S t <br /> �A LA 1 —9 Screen Length (from) S S <br /> �— Filter Pack (from);(to) :75-1 <br /> Inspector. �AA n�` Benronire (from)— So 'S^ (to)s <br /> Permit No. (from)_ (to) o s <br /> Drilling rig type <br /> Auger O.D. t.D. <br /> Drilling Company: I LOM . .,.. n Completion - Stove p e�clsnspe bo � <br /> (circle one) <br /> Driller. <br /> Consultant — — casing <br /> height <br /> Geologist p WIT <br /> SPECIAL PERMIT INFO. CCti:'LLET10N C7ASTy�px <br /> m:nd Statact �t``TCN <br /> Distance to sewer line C <br /> Domestic �--- <br /> well on site . ) <br /> ]f yes, location andn prw( <br /> ranee - <br /> SO.,tv- ft. <br /> SS ft 3 ft <br /> _ a <br /> SAMPLING <br /> c <br /> Holding — dorad <br /> Temperature / <br /> Methodtoc�cn = = B <br /> _ , _- <br /> Screen n Mprloo brava <br /> Tracking Sheet . (y/ n ) <br /> SPOILSfi. <br /> Storage Method o <br /> Contamination Noted - ( MATER1ALSiD <br /> Storage Locar'on EVE[OPMENT <br /> �l'_-St'('A. 40 <br /> Casing <br /> G2_ O nNG — �_ft- Screen <br /> Slot size fr. <br /> o <br /> Bags cement_[3 <br /> Depth to water Buckets bent ....� ; <br /> Mix Ratio ( � Bags sand/ <br /> lnstallaaon Method S —� � gravel v y <br /> Filter Pack type/size u v1A .�_. _ <br /> QuantityInstalled �, ( 3U Surge Block: - it ) <br /> EH 29 29 Discussed with geologist: - (y/fli <br /> Type of method �lJ� <br />