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MONITORING WELL INSTALLATION REPORT <br /> Date: IC / / CONSTRUCTION <br /> Premise Address: w � CaM.� 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 /> Consultants �- d '4 <br /> Geologist •.� —ev, <br /> ABOVE-GRCUND <br /> COMPLETION COMPL.�C� WMN <br /> PLETICN <br /> SPECIAL PERMIT INFO. Ground Sutact <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft. <br /> R. <br /> y. <br /> SAMPLING tloroi <br /> soden <br /> Holding Temperature gnvw Pack <br /> Method UOA <br /> _ <br /> Screening Method .;' <br /> Tracking Sheet - n ) -�' _ <br /> SPOILS <br /> Storage Method MATE RIALS/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/ ii ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of mediod <br /> EH 29 29 <br />