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MONITORING WELL INSTALLATION REPORT <br /> lCONSTRUC'I'I ON <br /> Date )-s <br /> � Total Depth (to) <br /> Premise Address: 65 Screen Length (fram) Z <br /> Filter Pack (from)--2: (to) <br /> Well No.: Bentonite (from) (to) `/ <br /> Grout (from `r (to) <br /> Inspector: Drilling rig )e <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 ABOVEGROUND �tSTY-BOX <br /> Cp�LETION PLETICN <br /> amr�d surixyr <br /> SPECIAL PERMIT INFD. <br /> grout <br /> Distance to sewer line �/�^' — l 5 <br /> fl' <br /> Domestic well on site - (y/�) <br /> fl <br /> If yes, location and distance - ' <br /> o. A <br /> O <br /> :Foiled .;: C - <br /> SAMPLING sac*n x __ <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y) n ) <br /> SPOILS <br /> Storage Method, MATERIALS EVELOPMENT <br /> Contamination Noted - (y/ Casing type a 'IF VC, 5�1n <br /> Storage Location Blank ft. Screen o fr <br /> Slot size _ <br /> GRO=NG Bags cement <br /> Buckets bentonite <br /> Depth to water f' / Bags sand/gravel <br /> Mix Ratios Filter Pack typegrn <br /> Installation Method Surge Block: - ) <br /> Quantity Installed o Discussed with geologist: - Cyj n ) <br /> Type of method <br /> EH 29 29 © er, S <br /> co <br /> ( [�� � <br />