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MONITORING WELL INSTALLATION REPORT <br /> J ! 1 <br /> �G�./t,1, LV� <br /> Date: 6) CONSTRUCTION <br /> Premise Address: �-� Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> I/ Bentonite (from) (to) <br /> Inspector. � � Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant i-71 T <br /> '4 <br /> Geologist <br /> A$OVE-GACUND C>�iJSTY-80X <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line ofout <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - ft• <br /> ft. <br /> a <br /> SAMPLING — <br /> ttorai <br /> / aocticn <br /> L", N - <br /> Holding Tep�ature (� _ gnvw PackMethod (/ <br /> Screenin;Method A)d '' <br /> Tracking Sheet n) ` — <br /> A _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <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 /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/n) <br /> Type of method <br /> EH 29 29 <br />