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Premise Address: \ el <br />Well No.: of\V.1— Isc(2303 <br />Inspector: j..4A,AAE- <br />Permit No. ip Z TS4 4- 6,2 bi <br />Drilling Company: t2--S-1-- <br />Total Depth <br />Screen Length (from) (to) <br />Filter Pack (from) (to) <br />Bentonite (from) (to) <br />Grout (from) (to) <br />Drilling rig type <br />Auger 0.D. I.D. <br />Completion - Stove pipe/christie box (circle one) <br />Driller: <br />Consultant 1 r <br />Geologist <br /> <br />pt kjocei50 <br /> <br />MONITORING WELL INSTALLATION REPORT <br />Date: CONSTRUCTION <br /> <br />ABOVE-GROUND <br />COMPLETION <br />casing <br />height <br />SPECIAL PERMIT INFO. <br />Distance to sewer_line <br />Domestic well on site - <br />If yes, location an <br />SAMPLING <br />Holding Temperature <br />Method <br />Screening Meth <br />Tracking S14t - ( y / n) <br />SPOILS <br />cklq, <br />C) Storage Location <br />GROUTING <br />Depth to water <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />Ground Surface <br />MATERIALS/DEVELOPMENT <br />Casing type c§ "el) <br />Blank ft. Screen ft. <br />Slot size k 0 2-0 <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size 14F-.3 4- 21/IL <br />Surge Block: - ( y / n) <br />Discussed with geologist: - ( y / n ) <br />Type of method <br />Storage Method ;C <br />Contamination Noted - ( <br />EH 29 29