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MONITORING WELL INSTALLATION REPORT <br /> I 1 to CONSTRUCTION <br /> Date: <br /> Total Depth <br /> Premise Address: Screen Length (from) (Eo)— <br /> M a l (� Filter Pack (from) (to) <br /> Well No.: Bentonite (from) (to) <br /> Grout (from) (to) <br /> Inspector. Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller• - height <br /> Consultant ► <br /> Geologist AEE S E-GRCUND C -S*—r`f-30X <br /> 00MPL.`T+ON GC{r4 FnCN <br /> C�uc�d Suiaas <br /> SPECIAL PERMIT INFO. <br /> proc.•t <br /> Distance to sewer line �41 <br /> ft. <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - <br /> O <br /> SAMPLING _ 3 <br /> :ocicn <br /> Holding Temperature -= <br /> Method <br /> Screening Method = <br /> Tracking Sheet - (y/ n) a _ <br /> � tt. -- <br /> Tb 56 <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method <br /> Contamination Noted - (y/ n) Casing type <br /> Storage Location BlankL 1 fc. Screen_ —h <br /> Slot size O .ell b <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel 2 b d <br /> Depth to water Filter Pack type/size <br /> Mix Rados Surge Block: - (y/ n ) <br /> ipstallation Method Discussed vrith geologist: n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />