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MONITORING WELL INSTALLATION REPOpci <br /> Date: � ' CONSTRUCTION <br /> Premise Address: 5 `� Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. X4, Grout (from) (to) <br /> .Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company-.— <br /> Driller'. <br /> ompany:Driller'. casing <br /> p <br /> height <br /> Consultant <br /> Geologist '- <br /> /l.°AYE-GACt1tJD C�W�STY-30X <br /> COWPLEDON GOMPL=-TICN <br /> SPECIAL PERMIT INFO. Ground Suiacs <br /> Distance to sever line Z <br /> Qro�t <br /> Domestic well on site - (y/ n Rz " ft. <br /> If yes, location and distance - ft, <br /> ft. <br /> SAMPLING <br /> soden <br /> Holding Temperature — <br /> Method <br /> Screenin;Method <br /> Tracking Sheet (y/ n ) _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted- (y/n) �� <br /> Storage Location Casing type <br /> Blank ft. Screen R- <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 /> dpstallation Method Surge Block: - (y/n ) <br /> Quantity Installed Discussed vrith geologist: - (y/n) <br /> Type of method — <br /> EH 29 29. - <br />