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MONITORING WELL INSTALLATION REPORT <br /> CONsrRUCT[ON <br /> Date: // / 7 ,^ / <br /> ` ` 5� ( Total Depth (to) <br /> Premise Address: Screen Length Cfcom)�—Cto)_ <br /> 30 _ Filter Pack Cfro —. -- to) <br /> Well No: d Bentonite (from„1) S S <br /> GIOut (fT943)�— —� —(to) <br /> Inspector. Drilling rig type /�5 1 <br /> Auger O.D. �'^�P� I.D. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: V <br /> casing <br /> Driller: he;ght <br /> Consultant <br /> Geologist �Oh �d� ABavE-GftwtCUND CM-Box <br /> CSP LEnolsl Cpt,t?t:'TION <br /> �,_Cxa:tY1 Suixt <br /> SPECIAL PERMIT INFO- <br /> Dist ance <br /> NFO.Distance to sewer line Ste' —=-Il• <br /> Domestic well on site ( Y/ n) 5 ft. <br /> If yes, location and distance <br /> o <br /> = o <br /> SAMPLING <br /> Holding Temperature <br /> Method . — <br /> Screen'ngMethod <br /> Sheet - (y/ n) = = ft. <br /> Tracking I Vl h, <br /> NC 11 !7 <br /> SPOILS <br /> MATERI AIS/DLOPMENT <br /> Storage Method el v��rJ <br /> Contamination Noted- (y/ n) Cuing type f <br /> Storage Location Blank ft Screen <br /> Slot size d M <br /> Bags cement <br /> GROUTING Buckets bentonite (Y <br /> Bags sand/gravcl <br /> Depth to water Filter Pack type/siz <br /> Mix Rados Surge Block: - /n) <br /> pstalladon Method Discussed with eologi t: <br /> Quantity Installed Type ofmcdiod <br /> EH 29 29 <br />