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` 4 <br /> ` MONITORING WELL INSTALLATION REPORT <br /> 1 Wo C <br /> Cc l Ins <br /> Date. <br /> .t CONSTRUCTION <br /> Premise Address: 6 � <br /> f.� Total Depth 5L <br /> Well No.: - r Screen:Lcngth (from)_ <br /> g Filter Pack (from) SO <br /> Inspector: Q. - -Bentonite (from)=_4�- TO �( ) <br /> 1l�no�n�f- (from) <br /> Permit No, Drilling ng,type <br /> ` - ; ' � , <br /> Auger O.D. I.D. <br /> Drilling Company: 4 .� Completion =Stove pipe/chrisde box (circle one) <br /> Driller: <br /> �.:.. casing � w <br /> Const: r` 1Lhe?ght <br /> ltani t <br /> Geologist t cR <br /> ABOVE-GRCUND . <br /> co&gL.ETION ?STY-aox <br /> SPECIAL PERMIT INFO. - r � (,t`� COMPL-CTICN <br /> Distariceto sewer line <br /> Domestic well on site y nSave <br /> If yes, location and dista �► ' - ft. <br /> ft. <br /> M e <br /> SAMPLING <br /> Holding Temperature sacicn <br /> Method " .. �S <br /> Screening Method- <br /> Tracking <br /> ethod Tracking Sheet (.y/ n ) — <br /> fo <br /> SPS �.....tt. <br /> Fy , <br /> Storage Method <br /> Contamination Noted - ( /n}. <br /> MATERIALS EVEI,OPMENT f <br /> Storage Location ,, k <br /> Casing type - V <br /> e� C.....h�,. Blank_ {�_fr Screen ft. <br /> GROUHZNGG Slot size <br /> . Bags cement <br /> Depth to water-- —7V Buckets bentonite` , <br /> Mix Ratios Bags sand/gravel �Y 1=<, ' <br /> 42 <br /> Installation Meth ' S Filter Pack type/size ` <br /> Quantity Insrallcd w - � Suxge Block: - (y/ n ) <br /> Qiscussed'with geologist: - (y/ n ) <br /> EH 29 29Type of nctliod ' <br />