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MONITORING WELL INSTALLATION REPORT <br /> Date: ? (l b� CONSTRUCTION <br /> Premise Address:- ? � �• � '(�� Total Depth <br /> • _ q e Screen Length (from)- <br /> Well No.: w •(I �41 r / 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 /> l Driller: casing <br /> hes.ght <br /> Consultant ,�• <br /> Geologist \ -�► <br /> • ABOVE-G R CUND <br /> CO Mir'LETfO N C2_nzTY-B30X <br /> CO{�. =-ncN.. <br /> SPECIAL PERMIT TNI=O. ��Suia�a <br /> Distance to server line <br /> Domestic well onsite - (y/n) <br /> If yes, Iocation and distance - ft. <br /> v' o <br /> SAMPLING <br /> tiloC.a.� :ii c <br /> Holding Te perature <br /> MethodUif) - _ g�`r°t Pack <br /> g <br /> " ScreeninMe h <br /> Tracking Sheet - / n ) <br /> SPOILS • • • i a <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) �> <br /> Storage Location '' Casing type <br /> Blank ft. Screen fr. <br /> Slot size <br /> GROUTING Bags;cement <br /> r ' Buckets bentonite - <br /> Depth to water r Bags sand/graveI <br /> Mix Ratios _ `. Filter Pack type/size <br /> installation Method Surge Block: - (y <br /> Quantity Installed Discussed vrith geologist: (y/ ri ) <br /> • - Type of method <br /> EH 29 29. . <br />