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MONITORING WELL INSTALLAnON REPORT <br /> l <br /> Date: r30to•( <br /> 1 CON_ STRUCI7ON <br /> Premise Address; <br /> Total Depth <br /> Well No.: _ Screen Length (from) _(to)�_ <br /> Filter Pack (from))_(to)�� <br /> inspector. U �]G Ann L Bentonite (from) <br /> (to) -w <br /> . Grout (from) -- <br /> Permit No. Drilling rig type <br /> Auger O.D. _ I.D. <br /> Drll ng Company Completion - <br /> Stove pipe/duisiebox <br /> (circle one) <br /> Driller. q„� <br /> Consultant casing <br /> s } TM7 <br /> height <br /> Geologist - 1 e <br /> � <br /> AP.OVE-GRCUND ` <br /> SPECIAL PERMIT INFO. C0?19L`DCN �AS�YdoX ' <br /> Crcc:nd Suiacy N <br /> Distance to sewer line <br /> Domestic well on si - Y/n ) ➢r«t <br /> I;yes, loran, d distance - <br /> �L ft. <br /> f1. ft. <br /> o <br /> SAMPLING _ <br /> c <br /> ifcrnd <br /> Holding Temperature sac-;cn 3 <br /> Method _— <br /> Screening Method _ yTavn7yack <br /> Tracking Sheet - (y/ n ) <br /> _— <br /> SPOILS \� ft. <br /> ff. <br /> Storage Method_9 <br /> Contamination Noted • ( ��w wn 4 MATERIALS/DEVE[OPMENT <br /> Storage Location. �.�Fn <br /> Casing type_ PU� <br /> CR Slots e�—� Screen h <br /> � OZr, <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix RatiosBags sand/gravcl <br /> lnstallapon Method Filrer Pack type/size <br /> Quantity Installed Surge Block: - <br /> Discussed with geologist: - <br /> ErI 29 29 Type of method (y/ n ) <br /> - _ M <br />