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V slw� <br /> MONITORING WELL INSTALLATION REPORT <br /> CONSTRT UCTION CPbA41•y <br /> Date: <br /> C.CJtc Total Depth L07 / <br /> Premise Address: Screen Length (from) (to)_ <br /> C P 1= tel r '"'� {` Filter Pack (from) (to) <br /> Well No.: Bentonite (from) (to) <br /> Grout (from) (to) <br /> Inspector. Drilling rig type_ 0 <br /> Permit No. Auger O.D. 2 1�� I.D. <br /> Del v), w-Y ec) Completion- Stove pipe/cluistie box (circle one) <br /> Drilling Company', `�1 <br /> i casing <br /> Driller: ��''� �– —Fheight <br /> Consultant <br /> Geologist c� i3w e 0' -- <br /> /,k30YE-G R CL1ND c1HFtsSTY-34X <br /> OO MPLETC N COMPLEMN <br /> Gmurd 5�xtact <br /> SPECIAL PERMIT INFO. <br /> grant <br /> Distance to sewer line ft. <br /> Domestic well on site .- (y/ n) ft. <br /> If yes, location and distance - <br /> v » <br /> P.= <br /> SAMPLING soc9cn <br /> r'"V14 Pack <br /> Holding Temperature <br /> r- <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n) w <br /> ti. <br /> SP TLS <br /> MATERIM:gj DEVEt OPMENT <br /> Storage Method <br /> Contamination Noted - (y/n) Casing type <br /> Storage Location Blank ft. Screen h' <br /> Slot size <br /> Bags cement <br /> GR_ OU'T'ING Buckets bentonite <br /> N 39 Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/ n} <br /> Installation Method Discussed with geologist: - {y/ n ) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />