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r <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: �/ �/b 7 /' [/, t /A CONSTRUCTION�I <br /> Premise Address:�O(b��2 s "/C/ Total Depth >Z <br /> Screen Length (from) (to) <br /> Well No:_ O Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. Grout (ft (to) <br /> Drilling rig type ( rr <br /> Permit No. )069 AugerO-D. I.D. <br /> S Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: —,F he±ght <br /> Consultant <br /> Geologic[ <br /> CO r'LETCN Ck-ASTY-a7X <br /> Cg4.r'L:-TIC4 <br /> SPECIAL PERMIT INFO. Crxrd Sul <br /> prat <br /> Distance to :ewer line <br /> Domestic well on site - ( y/ n ) I ' <br /> if yes, location and distance - N <br /> h. <br /> = c <br /> SAMPLING LYS l v� �t r ni <br /> — <br /> Holding Temperature <br /> Method "= — <br /> Screening Method = <br /> Tracking Sheet - (y/ n) <br /> SPOILS <br /> Storage Method MATERIALS EVEI.OP NT <br /> Contamination Noted - (y/ n) Casing type <br /> Storage Location Blren <br /> Iz Screen__ ��—h' <br /> Sl <br /> GROUTING Bant <br /> Bunto ' e Bagr el Depth to water3 2-'�� — Fie/sizeMizRatios ^,Installation Method Su : - (y/o )Quantity Installed DiYrith geologist: - (y/ n)Tthod ---- <br /> EH 29 29 <br />