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MONITORING WELL INSTALLATION REPORT <br /> CONSTRUCTION <br /> Date: <br /> Total Depth <br /> Premise Address:�- / U Screen Length (from) <br /> Filter Pack (from) <br /> Well No.: Bentonite (from) (to) <br /> Grout (from) (to) <br /> Inspector: Drilling rig type <br /> Auger O-D. I.D. <br /> Permit No. Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: ` height <br /> Consultant„ ' <br /> Geologist ABOVE-G RCUND cHRZTY 4= <br /> CONPLETCN coMpt_mcrr <br /> Q=rsd Sutaca <br /> SPECIAL PERMIT INFO. <br /> procR <br /> Distance to sewer line - <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - ' <br /> O <br /> SAMPLING sior.A.i <br /> sacicn �'" <br /> Holding Temperature <br /> — pzvat Cit <br /> Method sa, — <br /> Screening Method <br /> .4. <br /> Tracking Shcet - (y/ n) <br /> •� ft. <br /> SPOILS <br /> Storage Method MATERIALS EVELOPMENT <br /> Contamination Noted - (y/ n) Casing type <br /> Storage Location Blank fL Screen__---.ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite,_ <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/ 11 ) <br /> Installation Method Discussed with geologist: - (y/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />