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MONITORING WELL INSTALLATION REP. rtT <br /> Date: L 196 / Nn/ <br /> CONSTRUCTION <br /> Premise Address : CIOVCJ / /mob'[" 4t 1'2454 - S*t e L t� Total Depth <br /> Screen Length (from) (to) <br /> Well No. : 0 Filter Pack (from) Cto) <br /> Benronire (from) Cto) <br /> Inspector. y �, Grour (from) (to) <br /> Drilling rig type <br /> Permit No . Auger O .D. LD. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Cas lIIrj <br /> Driller. =7 height <br /> I i1 <br /> C�tant <br /> Geor [ RC �\ <br /> ABCVEvflCUNO q..Ars., Y-3OX <br /> CCvF L ICN C,- MPLETiCN <br /> SPECIAL PERMIT INFO . �� � 9trtaca — <br /> r <br /> Qra.K <br /> Distance to sewer line <br /> Domestic well on site • ( y / n ) d- <br /> [f yes, location and distance - `f <br /> ft. �— <br /> SAMPLING Blamed - o <br /> ax:cn � <br /> Holding Temperature <br /> Method <br /> Screening Method = <br /> Tracking Sheer - ( y / n ) <br /> SPOILS <br /> Storage Method /$ i k MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y / n ) �� .�� �) <br /> Storage Location ACasing type <br /> r �� fr <br /> Blank fr. Screen <br /> Slot size <br /> GROUTING Bags cement <br /> _ Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Fater Pack typesize <br /> Mix Ratios Surge Block: - ( y / n ) <br /> Installation Method Discussed with geologist: - ( y <br /> Quantity Installed Type of method <br /> EH 29 29 <br />