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MONITORING WELL INSTALLATION REPORT <br /> ��r�2� q t l3 �.��4-• <br /> CONSTRUCTION <br /> Date: <br /> Total Depth <br /> Premise Address: ` Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Well No.: "1` Bentonite (from) (to) <br /> . Grout (from) (to) <br /> Inspector Drilling rig type <br /> Permit No. Auger O.D. f HT__ LD. <br /> Completion - Stove pipe/chnstie box (circle one) <br /> Drilling Company: <br /> 71casing <br /> � <br /> Driller: height <br /> Consultant '�; <br /> Geologist ABOVE-GRCUND C�-S;STY.aox <br /> COWLETCN COMPLETION <br /> -- Orwnd Stztaca <br /> SPECIAL PERMIT INFO. <br /> prat <br /> Distance to sewer line ? It <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - <br /> _ o <br /> _ c <br /> tlorod = � <br /> SAMPLING =i �soc cn <br /> Holding Temperature ` _ l <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/n ) <' _ tt <br /> tt. <br /> SPOILS -17' <br /> MATERI ALS(DE V ELOPMENT <br /> Storage Method ( rr <br /> Contamination Noted - (y/ n ) Casing type <br /> Storage Location Blank fc Screen_-- — <br /> Slot size <br /> Bags cement <br /> GROLiTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water___/ % Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/ n ) <br /> ,installation Method Discussed with geologist: - ( y/ n) <br /> Quantity Installed Type of method <br /> EH 29.29 <br />