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• r <br /> MONITORING WELL INSTALLATION REPORT <br /> Date• ! 7�C CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (co) <br /> / Bentonite (from) (to) <br /> Inspector. /�/� �^ ; Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing. <br /> he; <br /> Consultant �� C 'V <br /> an <br /> Geologists <br /> • AESOVE-GRCUND CI-niM_Box <br /> CONPLETION CONN ===N <br /> SPECIAL PERMIT INFO. Ground Scztacs <br /> Distance to sewer line pra <br /> Domestic.well on site.- (y/n) <br /> If yes, location and distance - <br /> • <br /> ( <br /> SAMPLING ( ^ <br /> L/ A< t1oCv,� :i c <br /> Holding Temperature r <br /> Method tfi�;� <br /> Screening Method "'= _ <br /> Tracking Sheet - (y/n ) .r <br /> 4 rti. <br /> SPOILS <br /> T . • <br /> Storage Method MATERIALS/DEVEI.OPMENT <br /> Contamination Noted . (y/n) <br /> Storage Location Casing type <br /> Blank fc Screen fr. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> ips[allation Method Surge Block: - (y/n ) <br /> Quantity Installed Discussed vAth geologist: - (y/n ) <br /> Type of method <br /> EH 29 29. . <br />