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- MONITORING WELL INSTALIATEON REPORT <br /> 12,Jr c cot _9TR T1 ON <br /> Date: <br /> ' � Total D^-gth (to)_� <br /> z � <br /> Screen Length (from) <br /> Premise Address: <br /> L � Filter Pack <br /> Well No.: d Bentonite <br /> Grout (from) <br /> ector, <br /> Ins . �" Drilling rig type <br /> p I.D. <br /> Auger O.D. <br /> Completion - Stove pipe/clu-istie box (circle one) <br /> Fermi[No. <br /> Drilling Comp�Y� casing <br /> he;ght <br /> Fm IV <br /> Cons�sltant S - <br /> Geologist ��-GRCUNa t�.ST` -5Ox <br /> COWPL_E ON ?L iicN <br /> Cxxc-d Su-fac� <br /> SPECIAL PERMIT INFO• gca.t <br /> Distance to sewer•line tt' <br /> Domestic WC11 on Site = C y ft- <br /> If yes, location and distance - <br /> � M <br /> O <br /> C <br /> O <br /> Holding Temperature <br /> Method ' <br /> Screening Method = ' : <br /> Tracking Sheet - C Y/ n = ~ . <br /> . <br /> SP_ OILS [OPmF_ <br /> ' MATERIALS IMVE • . <br /> Storage Method Qj' 2 4� <br /> Contamination Noted - C Y/ �� Casing type ` <br /> Screen <br /> Storage Location <br /> Blank ft <br /> Slot sue <br /> Bags cement <br /> GR�G { Buckets bentonite <br /> Bags sand/gravcl <br /> Depth to water �- !� Filter Pack type/size <br /> Mix Ratios Surge Block: - C Y <br /> -J.pstalladon Method Discussed with geologist: - (y/n) <br /> Quantity Installed Type of ractllod <br /> EH 29 29 <br />