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MONITORING WELL INSTALLATION REPORT <br /> Date:_ Q 2s j pZ CON57RUCT10N <br /> Premise Address: f,l C2 n n e -p Total Depth Z 1 <br /> i <br /> Well No.: Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Bentonite (from) (to) N <br /> Inspector — I�� L. o� q Grout (from)- (to) <br /> E �* `T— <br /> Permit No. Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Company-. Completion - Stove pipe/christie box (circle one)— <br /> Driller: 'j ntiA <br /> _ _ casing <br /> Consultant :S t7 rr f c_-- �� � height <br /> Geologist_ C 1 C <br /> ABCVE-GACUND <br /> COMPLLETICN C�GuTY-aCX <br /> SPECIAL PERMIT WO. COMPLET1ct4 <br /> C3rtt:nd Suiaca <br /> Distance to sewer line <br /> Domestic well on site - <br /> If yes, location and stance n ) <br /> - a <br /> — m <br /> SAMPLING - <br /> tlonwi = c <br /> Holding Temperature j e% soelcn 3 <br /> Method <br /> Screening memoa�[[) _ <br /> Tracking Shcet -U/ n ) <br /> SPOILS la l tt. = Z ft. <br /> Storage Method <br /> Contamination Noted - (y/n ) MATERIALS/DEVEI OPMENT <br /> Storage Location C <br /> I Casinge <br /> type i- <br /> Blank <br /> GROUTING Slot size 2p <br /> h Screen h <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ranos Bags sand/gravei v Z <br /> Installation Method �' Filter Pack type/size <br /> Quantity Installed n/ Surge Block: - (y <br /> Discussed With geologist: • (y/ n ) <br /> EH 29 29 Type of method <br /> /` .d <br />