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S..ONITORING WELL INSTALLATION REP{,,,� <br /> Date: 11 7-C lor a CONSTRUC'T'ION <br /> Premise Address �' y /U" Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (fro (t <br /> Bentonite (fro ) ( ) <br /> Inspector. Grout (fr m o) <br /> Drilling rig type <br /> Permit No. 0 Auger O.D. I.D. <br /> Completion - Stove pipe/cliristie box (circle one) <br /> Drilling Company:_ <br /> Driller: )DA6 5hsan-en. _ casing <br /> �' he;ght <br /> Consultant ��c <br /> Geologist <br /> ROMPLET <br /> D C�fR -8CX <br /> N COMPLEMN <br /> SPECIAL PERMIT INFO. Civ nd Swfac+ <br /> Distance to sewer lineL/ 9feut <br /> Domestic well on site - (y ft. <br /> If yes, location and distance - ii. <br /> — a <br /> SAMPLING sloGad = C <br /> �-0�Hold'ng <br /> T perature " gM,S <br /> pack <br /> Method OAx: _ <br /> Screening Method t �" <br /> Tracking Sheet y n ) <br /> SPOILS <br /> Storage Method ATERIALS VELOPMENT <br /> Contamination Noted - n } <br /> Storage Locatio - Vank <br /> e <br /> ft. Screen ft. <br /> GROUTING en <br /> be tonite <br /> Depth to water 50-x- gravelMix Ratiosc type/size <br /> Installation Method l ck: - ( y/ n <br /> Quantity Installed d with geologi r. - (y/ nmethod <br /> EH 29 29 <br />