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ABOVE-GROUND <br />OOMPLETION <br />casing <br />height <br />Ground St.rfact <br />MONITORING WELL INSTALLATION REPOrLf <br />/t9- • 3 011.-. 54-4(444) <br />Premise Address: ;7„.1/ AJ. 1644ot , <br />Drilling Company:_-- <br />6 iea-er-4 <br />Consultant /t/ <br />Geologist 6-ie V Rifiatiaaee. <br />SPECIAL PERMIT INFO. <br />Distance to sewer line <br />Domestic well on site - Cy? n) <br />If yes, location and distance <br />SAMPLING <br />Holding Temperature <br />Method ?,$° 550E%r7 <br />Screening Method /Vox-A <br />Tracking Sheet - n) • <br />SPOILS <br />Storage Method al-1-1-49/ <br />Contamination Noted - ( y 4:0 /,1 Storage Location <br />GROUTING <br />--...-% .</) ..---- Depth to water i <br />Mix Ratios / 7rfr" 74" <br />Installation Method --k-‘4444-A /1•4€414-e-#' <br />Quantity Installed fp )(- <br />del <br />EH 29 29 <br />CONSTRUCTION <br />Total Depth <br />Screen Length (from) 90 (to) /00 <br />Filter Pack (from) /D(:: (to) <br />Bentonite (from) BR. (to) <br />Grout (from) g‘:, (to) <br />Drilling rig type <br />Auger 0.1). I.D. <br />Completion - Stove pipe/christie box (circle one) <br />MATERIALS/DEVELOPMENT <br />Blank VC) ft. Screen /0 ft. <br />Casing typetype <br />Slot size . 2-0 <br />P <br />Bags cement /0 "1" <br />Buckets bentonite / 141--ertzel 7-C) <br />Bags sand/gravel 3 qz <br />Filter Pack type/size di a <br />Surge Block: - ( y <br />Discussed with geologist: - ( y <br />Type of method <br />Date: <br />Well No.: <br />Inspector: <br />Permit No. <br />Driller: <br />4a//6 (/:4)