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MONITORING WELL INSTALLATION REPORT <br /> Date:_ C / Z-fJd z2 CONSTRUCTION <br /> Premise Address: Total Depth <br /> Well No.__ } Screen Length (from) <br /> Filter Pack <br /> inspector- I Bentonite (from) 5'0 (to) 5-7 _ <br /> ^ter 6 Grout (from) 44- (to)— <br /> Permit No. z� Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Comparty:� Completion - Stove pipe/duisdelox (cir— cle <br /> Driller. -P AAA f <br /> casing <br /> Consiltant�C.� q� v he±qht <br /> Geologist IMAt <br /> A,'CVE-GRCUND <br /> =,VL_c710N CFiA75Ty-30X <br /> SPECIAL PERMIT INFO. CCMPLEMCN <br /> Cxwnd Su1ac� <br /> Distance to sewer line <br /> Domestic wellon site - otart <br /> If yes, location and dist(y/n <br /> 5� rt. <br /> _ - a <br /> SAMPLING <br /> 0 <br /> �locai — c <br /> Holding Temperature_ socicn = 3 <br /> Method _ <br /> c� -� = p-avul pads <br /> Screening , od -" <br /> Trackin hcet - (Y/ n ) _ <br /> SPOILS —R. <br /> Storage Method_tsln P�r� � <br /> Contamination Noted - (y/n) MATERIALS/DEVE[OPMENT <br /> Storage Location n„e. <br /> Casing type Z PFJ <br /> Blank ft, Screen <br /> GR�NG Slot size 020 <br /> Bags cement w l /�wu <br /> Depth to water-----:,�& 2 ` Buckets bcntomte_ �— <br /> Mix Ratios Bags sand/gravel_ } (mss <br /> Installation Method Filter Pack type/stze:Vg �--� <br /> Quantity Installed N i D Surge Block: - (y/"I <br /> Discussed with geologist-. - (y <br /> EH 29 29 Type of method <br />