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r REPORT <br /> y r .MONITORING WE.LI•�INS'T'AL ►TION <br /> CONST4tUCTI ON <br /> Date: ! ` <br /> Total Depth <br /> Premise Address: ff Screen Length (from) (to) � <br /> Filter Pack (fro(to)� <br /> Well No. Bentonite {to}_ <br /> . G ( rrerouC fro ) <br /> Inspector: Drilling Hg type I.D. <br /> Auger O.D. c shristie box {circle one} <br /> Permit No. Completion -Stove pip / <br /> Drilling <br /> casing <br /> ' � <br /> 77- <br /> he-ght ,�, <br /> Driller• - I <br /> 11 <br /> Consultant <br /> ABOVE-GFtCQND CksRSTY-a0X <br /> COppLETKNJ CohLoL—=n0N <br /> SPECIAL PERMIT INFO- pra.•C <br /> 1 ft. <br /> Distance to sewer line <br /> Domestic well on site.; (Y1 n) ft. <br /> IE yes,location and distance • ���, <br /> SLM <br /> P-UN(� i4GTCr1 r qnvig Pack <br /> Holding Temperature •rc <br /> Method . <br /> Screening Method . <br /> Sheet - {Y/ n = ' <br /> Tracking ��tt. �--- •. <br /> SPO LS [.OPMENT <br /> MATERIALS <br /> Storage Method <br /> Contamination Noted - (Y/ n) Casing type f <br /> Storage Location-------------------- gl fc. Screen <br /> Slot size` <br /> Bags cement <br /> GR�NG Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Ratios _ Surge Block: - (Y/n <br /> 4 istalladon Method Discussed vAth geologist: • (Y/n <br /> Quantity Installed Type of nethod <br /> EH 29 29 - <br />