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MONITORING WELL INSTALLATION REPORT <br /> Date;_$ IrS )O CONSTRUCTION <br /> Premise Address:_ bob (/ J {y(` Total Depth_ 1 9.5 ` <br /> Screen Length (from) (to)_ I �- <br /> Well No.: (A) Filter Pack (from) (to) t9. 0 <br /> Bentonite <br /> inspector: 1 (from) �.� (to)-9 <br /> l to yin rte_ Grout (from) / '(to)� _ <br /> Permit No. <br /> Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Company: <br /> Completion - Stove pipe/christie box (circle one) <br /> (,J(�(° <br /> Driller: casing <br /> height <br /> Consultant S 4ytn,�,-, r <br /> Geologist 'Fc?or -71ST � ,_ —E VT <br /> ABOVE-GROUND <br /> COMPLETION CHRISTY-BOX <br /> SPECIAL PERMIT INFO. Groundgurfacs COMPLETION <br /> Distance to sewer line proof <br /> Domestic well >and <br /> - ( <br /> if yes, location ' ance - tt• <br /> a <br /> — e <br /> SAMPLING = <br /> donad = 'c <br /> aactlon — � <br /> Holding Tempera = <br /> Method = vivo'Pack <br /> Screen• ethod _ Peuqutu°� <br /> Trg Sheet - (y/ n) — Y <br /> i •S tt. = 1 �s tt. <br /> SPOILS sa"e 19•f f{ <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing typeIf 19 V C <br /> Blank LO ft. Screen__3 •D ft. <br /> Slot size . O l0 <br /> GROUTING Bags cement <br /> Buckets bentonite z 6�! <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size �Zu"Pe-c. .,Alf <br /> Installation Method Surge Block: - ( y/ n ) 0e. <br /> Quantity Installed Discussed with geologist: - ( y <br /> EH 29 29 Type of method <br />