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MONITORING WELL INSTALLATION REP"KT <br /> +e <br /> C <br /> Date: <br /> C K colvs�rR_ucrlorr <br /> Total Depth <br /> Premise Address: _ � from) (to <br /> a� _ �� /J,n Filter P ark (from) (to) <br /> Well No.: (to) <br /> �• p / Bentonite (from) <br /> Grout (from) (to) <br /> [nspector: 1�� II [ Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. r Completion - Stove pipe/christie box (circle one) <br /> Drilling Company*-- <br /> �� casing <br /> Driller. 7Fheight <br /> � 7 T <br /> Consultant <br /> Geologist ABCYE-GRCUND ��-gqX <br /> &V °TION C.0 MPLZ_ CN <br /> G=nd Sufacs <br /> SPECIAL PERMIT INFO. , <br /> Distance to sewer line �- <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - <br /> s <br /> SAMPLING <br /> CQ1 Sp, } S&CR cn J <br /> `T — <br /> Holding Temperature — S°1 pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS S-o l S <br /> Storage Method �`(� MATERIALS/DEVELOPMENT <br /> /D _ LOPMENT <br /> Contaminati oted - (y/ n) J�!/ V <br /> Casing type <br /> Storage cation Blank ft, Sween <br /> S jvv Slot size <br /> GROUTING I Bags cement <br /> Buckets bentonite <br /> Depth to water ags sand gravel <br /> Mix Ratios AaA Ater Pack typesize <br /> Installation Method ��CS�j� urge Block: - C y/ n ) <br /> Quantity Installed �y �,i` Discussed with geologic ] C Y/ n) <br /> Type of method /I �1�211�. . <br /> EH 29 29 5gJ \�� I <br /> bro � Zo (Cs " i(c l- <br />