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MONITORING WELL INSTALLATION REPORT <br /> Date: �w ID CONSTRUCTION <br /> Premise Address:`t C3 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 /> Driller: casing <br /> height <br /> Consultant —WT <br /> Geologist <br /> ABOVE-GROUND <br /> COhii�LETf01+! C}R SW-a0X <br /> COMPLETION <br /> SPECIAL. PERMIT INFO. Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - {y/ n) <br /> If yes, location and distance - <br /> it. <br /> ft. <br /> q <br /> .a• '� <br /> SAMPLING 17 slort�d c <br /> soon a — <br /> Holding Temperaturegm�g pack <br /> '^ <br /> Method _ <br /> xs- <br /> Screening Method <br /> Tracking Sheet - {y/ n ) _ <br /> SPOILS t B <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/graveI <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 />