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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Tom 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. Anger O.D. ice• <br /> Completion-Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller. casing <br /> he; <br /> T ♦ T <br /> 6- <br /> Consultant <br /> Geologist ��� <br /> G"ArP:—�T'Al�t CHR2 Y-aCX <br /> CIO&PLEMN <br /> . SPECIAL PER.MIT INFO. C*=jd Su'hcr <br /> Distance to sewer line <br /> Domestic well on site - (y/ n} A fL <br /> If yes, location and distance - - I iL <br /> r <br /> O <br /> SAMPLING Wa6d <br /> ascon - <br /> Holding Temperature <br /> Method ` <br /> Screening Method _ <br /> Tracking sheet - (y/ n) — <br /> ;� !._= n <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) <br /> Storage Location Casing type <br /> Blank fr. Screen ft <br /> Slot size r <br /> GROU'�TNG 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/ n) <br /> Quantity installed Discussed with geologist: - (y <br /> Type of method <br /> EH 29 29 <br />