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MONITORING WELL INSTAUATION REPORT <br /> I <br /> D I CONS <br /> Date: r 71Z <br /> .ILW � vo lv- {/r• <br /> �1 S ( � h<< ✓ '� Total Depth r (to) <br /> Premise Address: Screen Length (from).—(to) <br /> Filter Pack (from) —(to) <br /> Well No: i� Bentonite (from)�— <br /> �L� _ Grout (from)_--(�o) <br /> inspector. Drilling rig type I.D. <br /> S Auger C.D. <br /> Permit No. Completion - Stove pipe/clutsde box (circle one) <br /> Drilling Company: tih - — <br /> cas:n4 <br /> Driller: I I he_5ht <br /> Consultant <br /> Geologist "ec A?,0VE-GRC(JND C-nnM-a0X <br /> b— 3S CAYPLE=N C0t,2PL--n0N <br /> SPECIAL PE NT INFO. (2' / 7 prat <br /> Distance to sewer line <br /> Domestic well on site .- (y/ n) h' <br /> if yes, location and distance - n, <br /> _ M <br /> O <br /> O <br /> C <br /> SAMPLING SQCIGM1 <br /> �. pr1Y9t F'a-�t- <br /> Holding Temperature s = <br /> Method <br /> Screening Method ': <br /> Sheet - (y/ n) = = n' <br /> Tracking <br /> SPOILS TERI i R/DEVELOPMENT <br /> i <br /> Storage Method <br /> Contamination No[ed- C Y/ n) Casing type fc Screen,.._-- <br /> Storage Location Blank <br /> Slot size <br /> Bags cement <br /> GROG Buckets bentonite <br /> Bags sand/grtvcl <br /> Depth to water <br /> Filter Pack type/size <br /> MiX Rados Surge Block: - (y/n) <br /> �tsmllation Method Discussed VAth geologist: - (Y/ n <br /> Quantity installed Type of ncthod <br /> EH 29 29. <br />