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t'. <br /> MONI'T'ORING WELL INSTALLA'IZON REPORT <br /> Date: <br /> �,� l b/bJ CONSTRUCTION <br /> �, �� -.w� P PG-r-r^-//'✓'fit"` Total Depth <br /> Premise Address' Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Well No., �-� r Bentonite (from) (to)- <br /> Grout <br /> to) -Grout (from) (to) <br /> Inspectord-__ Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller' -:F height <br /> 5 IV <br /> Consultant < <br /> Geologist ABOVE-GFtC.'UND C'%jRLM-30X <br /> COwLEMN Gp{PLEE-71CN <br /> Ground Sulacs <br /> SPECIAL PERMIT INFO. prat <br /> Distance to sewer line ' <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - ft. <br /> >_ C <br /> O <br /> ilorai _ <br /> SAMPLING socicn <br /> •N _ �av�F� <br /> Holding Temperature <br /> Method <br /> Screenin;Method —_ <br /> (y <br /> Tracking Sheet - /n) <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method ,i V�,. <br /> Contamination Noted- (y/ n) Casing type ft. <br /> Storage Location Blank c L ft- Screen <br /> c <br /> Slot size 0 , 01'e <br /> Bags cement <br /> GROLMNG Buckets bentonite <br /> Bags sand/gravcl <br /> Depth to water Filter Pack type/size <br /> Mix Rados Surge Block: - (y/11) <br /> Installation Method Discussed vAth geologist: - (y/ n) <br /> Quantity Installed Type of nethod <br /> EH 29 29 <br />