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MONITORING WELL INSTALLATION REPORT <br /> Dater t''3 _ CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: 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 /> casing <br /> Driller• —;F height <br /> Consultant <br /> Geologist Agovg..GFICUND a-SLSTY-Box <br /> CONFLETfON COMPI._ET1CN <br /> SPECIAL PERMIT INFO. Gourd Suface —+ <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - ft• <br /> o <br /> = a <br /> SAMPLING iloroi <br /> socicn �"� —_ <br /> Pack <br /> Holding Temperature =_ Gn`91 <br /> Method �= <br /> Screening Method <br /> Tracking Sheet - (y/ n) _ <br /> tt. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted- (y/ n) Casing type <br /> Storage Location Bl ft. Screen ft. <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Rados Surge Block: - (y/ n) <br /> i,ristalladon Method Discussed vrith geologist: - (y/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />