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MONITORING WELL INSTALLATION REPORT <br /> Date: rail/ l04 CONSTRUGnON , <br /> �/Lt(ti yea Total Depth <br /> Premise Address: E2 �' x Screen Len <br /> f, Filter Pack (from) (to) <br /> (from)—(to) , <br /> Well No.: Bentonite (from) (to) <br /> Inspector. Grout^� Drillin 3 ri type (ta) <br /> 3 e <br /> Auger O.D. _ I.D. <br /> Permit No. Comple rL <br /> *0 - Stove pipe/dutsde box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: height <br /> Consultant 4761 <br /> Geolc st �"'IY ABOVE-GRCUND Ch1RZTY30X <br /> COhQI_GTiON Cpt�?L'TICN <br /> Crarxl Suiact <br /> SPECIAL PERMIT INFO. <br /> prat <br /> Distance to sewer line <br /> Domestic well on site .- C Y/ n) <br /> If yes, location and distance - <br /> � M <br /> O <br /> .3 � <br /> SAMPLING tocicn <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Shoet - (Y/ n) <br /> ft, <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method <br /> Contamination Noted - (y/ n) Casing type f <br /> Storage Location Blank fr. Screen <br /> Slot size <br /> Bags cement <br /> GROL MNG Buckets bentonite <br /> Bags sand/zmvel <br /> Depth to water Fater Pack type/size <br /> MIX Ratios Surge Block: - (Y <br /> dTtstallarion Method Discussed with geologist: - (y/ n) <br /> Quantity Installed Type of medtod —� <br /> EH 29 29 <br />