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MONITORING WELL INSTALLATION REPORT <br /> Date: ( j�� CONSTRUCTION <br /> Premise Address: / Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. _ l� _ Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> Driller: casing <br /> /�_ height <br /> Consultant iSk l J s <br /> Geologist USS � ► � <br /> ABOVE-GROUND <br /> CO MW L Ef COMPLETION <br /> NCOMPLETION CNAI.M-BOX <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 - ft• <br /> ft. <br /> ft. <br /> 78 <br /> = m <br /> _ p <br /> = m <br /> SAMPLING 2 <br /> C <br /> �IoCad _ C <br /> /p &#cicn <br /> Holding T peratu-e <br /> Method__ <br /> Screening Method —_ <br /> Tracking Sheet - n ) _ <br /> ft. = ft. <br /> SPOILS <br /> Storage Method R MATERIALS/DEVELOPMENT <br /> Contamination Noted - n ) <br /> Storage Location O�', Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water— beis Bags sand/gravel <br /> Mix Ratios&aAE Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed U Discussed with geologist: ( y/ n ) <br /> EH 29 29 Type of method <br />