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MONITORING WELL INSTALLATION REPORT <br /> CONSTRUCTION <br /> Date: <br /> Total Depth (to) <br /> Premise Address: Screen Length (from) <br /> Filter Pack (from) (to) <br /> Well No.: Bentonite (from) (to) <br /> Grout (from) (to) <br /> Inspector. Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: height <br /> Consultant <br /> Geologist ABO` E-t'BC(JND C-HnS Y-30X <br /> oowLETION c4f 4PLEEEMN <br /> �—Cxa nd Suiact <br /> SPECIAL PERMIT INFO. gran <br /> Distance to sewer line - - ft. <br /> Domestic well on site .- C y/ n) ft. <br /> If yes, location and distance - ft <br /> _ � o <br /> slorai _ � <br /> SAMPLING soccn _ <br /> Holding Temperature <br /> Method <br /> _ <br /> Screening Method <br /> Tracking Shcet - (y/ n) '�' — ft. <br /> tt. <br /> SPOILS <br /> MATERI ALS/DEVELOPMENT <br /> Storage Method <br /> Contamination Noted - (y/ n) Casing type <br /> Storage Location Blank fr. Screen_ —f <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets bentonite. <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mi:t Rados Surge Block: - (y/11) <br /> ,installation Method Discussed with geologist: - (y/ n) <br /> Quantity installed Type of ncdtod <br /> EH 29 29. <br />