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MONITORING WELL INSTALLATION REPORT <br /> Date: OB 5w `2 CONSTRUCTION <br /> Premie Address: Total Depth <br /> Screen Length (fr <br /> om) ' <br /> (to) 122V <br /> Premise <br /> Well No: <br /> Filter Pack (from)—(Eo)- <br /> Bentonite <br /> from) (to)Bentonite (from)—(to)- <br /> Inspect.or'. <br /> from) (to)Inspector. lV C--H� Grout (from) i (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> �- Completion - Stove pipe/cluisde box (circle one) <br /> Drilling Company. ✓a <br /> `Icasing <br /> Driller'- ( � height <br /> Consultant V W I t4. - �� —WR N <br /> WT <br /> ME <br /> Geologist—Y-1 c 1 Y✓(f ABOVE-GaICUND <br /> COIVFLEC ON Cq',l?Li1CNtP Y�X <br /> CN <br /> SPECIAL PERMIT INFO. rd Su12c7 _� <br /> prat <br /> Distance to sewer line <br /> Domestic well on site .- (y/ n) <br /> If yes, location and distance - <br /> ft. <br /> _ M <br /> - O <br /> C <br /> - O <br /> SAMPLING secicn — <br /> Holding Temperature = lift. <br /> MethodScreening Method <br /> Tracking Sheet - (y/ nft. _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVEI.OPMENT <br /> Contamination Noted • (y/ n) Casing type <br /> Storage Location Bl� fr. Screenf <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to waterBags sand/gravel <br /> Miz Rados Fater Pack type/size <br /> .ipstallation Method Surge Block: - ( en) <br /> QuantiryInstalled Discussed With geologist: (y/ n) <br /> Type of nctltod <br /> EH 29 29 <br />