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fr <br /> MONITORING WELL INSTALLATION REPORT <br /> CONSTRUCTION <br /> Date: 1 <br /> Total Depth (to) <br /> Premise Address: Screen Length (from) — <br /> �b Filter Pack (from) (to) _ <br /> Well No.: Bentonite (from) (C0) <br /> Grout (from) (to) <br /> Inspector. Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/chris[ie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller• F height <br /> Consultant <br /> Geologist ABOVE-GRCUND CIXR S 1r-3ox <br /> CO wLET{O N –S1CN <br /> C3r�uc�d Suiacs <br /> SPECIAL PERMIT INFO. drat <br /> Distance to sewer line _ <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - ft _ <br /> )_ C <br /> O <br /> SAMPLING socicn <br /> ack <br /> Holding Temperature <br /> Method <br /> Screening Method 7 <br /> Tracking Shcet - (y/n) <br /> 3 <br /> SPOILS <br /> MATER16giEVEL.OPMENT <br /> Storage Method �� <br /> Contamination Noted- (y/ n) Casing type fr, <br /> Storage Location Blank [o ft. Screen <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/II) <br /> installation Method Discussed vAth geologist: - (y/ n) <br /> Quantity Installed Type of rnettzod <br /> EH 29 29 <br />