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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: T�2 l k� ��^�� Total Depth <br /> Screen Length (from) (to) <br /> Well No.: �► han.�_ Cy�� oar t-�� 0 Filter Pack (from) (to) <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_ght <br /> Consultant <br /> Geologist 1�°!WE-GROUND <br /> UND <br /> COMPL_EriGN C�rZ:STY oOX <br /> C�Mr'L="-TICK <br /> SPECIAL PERNET INFO. <br /> prcx.K <br /> Distance to sewer line <br /> Domestic well cn site - (y/ n ) f!. <br /> if yes, location and distance - <br /> ft. <br /> Y• - - o <br /> — C <br /> — o <br /> SAMPLING :lorai = <br /> Holding Temperature <br /> Method A S =i� -- <br /> Screening Method PLL <br /> Tracking Sheet - �} / n ) _ <br /> .�• tt. <br /> ft. — <br /> SPOILS <br /> Storage Method MATERIALS EVE[O MENT <br /> Contamination Noted - (Y/ n ) Casing type <br /> Storage Location Blank ft. Screen ft' <br /> • Slot size <br /> IIags cement <br /> GROUTING II Buckets bentoni e <br /> Depth to water b ",b ' (� 5 Bags sand/gra el <br /> � -S Fdter Pack e/size <br /> Miz RadosAn Surge Block: - (y/n ) <br /> -installation Method -Discussed v th geologist: (y/ n) <br /> Quantity Installed Type of m shod —� <br /> EH 29 29. . <br />