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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: n OD U Gil / ! Total Deph <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from)-(to)- <br /> Inspector'. <br /> from) (to)Inspector. Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/chriscle box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> Consultant <br /> � height <br /> Geologist ABOVE-GROUND <br /> CO W LETION CONAPL f ncN <br /> COMPL--TION <br /> SPECIAL PERMIT INFO. mrd S <br /> groat <br /> Distance to sewer line <br /> Domestic well on site - ( y/ n ) ft. <br /> If yes, location and distance - ft. <br /> ft. <br /> — - m <br /> = o <br /> a <br /> SAMPLING 1E <br /> sac'cn <br /> Holding Temperature 7 � ' _ _ �v�;-�K <br /> Method <br /> Screening Method = <br /> Tracking Sheet - ( y/ n ) <br /> n. _ = Ito <br /> SPOILS <br /> Storage Method MATFRIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type ft <br /> Blank ft. Screen <br /> Slot size <br /> GROUTING Bags cement <br /> rte/ Buckets bentonite <br /> Depth to water?�1 S� Bags sand/gravel <br /> Mix Rados Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />