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u <br /> MONITORING WELL INSTALLATION REPORT <br /> f <br /> Date: �I/7/0V / CONSTRUCTION <br />' Premise Address: /�b�( �` °� �' Total Depth <br /> r Screen Length (from) Cto) <br /> lj� �CI Filter Pack (from) (to) <br /> Well No.: / / Bentonite (from) (to) <br /> Inspector, cEfk, �� e Q <br /> Grout (from) Ro) <br /> Drilling rig type <br /> Auger O.D. I.D . <br /> Permit No. Completion - Stove pipe/dtrtstie box (circle one) <br /> Drilling Company: <br /> _ . <br /> cas ng <br /> Driller: � tvG f height <br /> Consultant <br />' Geologist ABOVEGFICUNO CFR sIl 3CX <br /> COA r' LETION CCkJ?L--TICK <br /> -- -_------� <br /> SPECIAL PERMIT INFO* G=nd Sutacs � <br /> proof <br /> Distance to server line <br /> Domestic well on site - ( Y / n ) fts <br /> fie <br /> if yes, location and distance - <br /> n . <br /> j = - m <br /> alar.�.i � <br /> SAMPLING soc cn <br /> Holding Temperature - t" 9t <br /> Method <br /> Screening Method = <br /> Tracking Sheet - ( y <br /> u <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y / n ) _ Gazing type <br /> Storage Location Blank ft. Screen_�h' <br /> Slot size —� <br /> GROVCING Bags cement <br /> Buckets bentonite <br /> Depth to tva[er Bags sand/gravel <br /> Filter Pack type/size <br /> Mit Ratios Surge Block: - ( y / n <br /> .installation Method Discussed vrith geologist: - ( y / n ) <br /> Quantity installed Type of mctltod —� <br /> EH 29 29 <br />