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MONITORING WELL INSTALLATION gEPORT <br /> CONSTRUCTION <br /> Date• I _ <br /> . E - Total Depth (to)_� <br /> Premise Address: Screen Length (from) <br /> r 1— Filter Pack (from) <br /> Well No.: Bentonite (from) <br /> Grout <br /> )----- <br /> Grout (from) (L0)------ <br /> Inspector. Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller' Fm V he?.ght <br /> Consultant <br /> Geologist °�•CVF--O`rjCUNfl Ck4Ft�ST1f-30X <br /> OO hF LETiO N GQtvIQL'�ICN <br /> Gmurd Sutact <br /> SPECIAL pERMIT INFO. greet <br /> Distance to sewer line It. <br /> Domestic well on site - (y/ n <br /> If yes, location and distance - <br /> •V O <br /> '= c <br /> _ Q <br /> ilOt•.� �r ..- C <br /> SAMPLING <br /> �. <br /> Holding Temperature <br /> Method — <br /> Screenin;Method — , <br /> Tracking Shcet - (y/ n <br /> SPOILS <br /> MATERI AISN [.OpMENT <br /> Storage Method <br /> Contamination Noted- (y/ n] Casing type fl, <br /> Storage Location Blank----.ft Screen <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/ n] <br /> Jpstallation Method Discussed with geologist: - (y/ n) <br /> Quantity IrutaIIed Type of rnc[hod <br /> EH 29 29 <br />