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MONITORING WELL INSTALLATION REPORT <br /> Date `' CONSTRLf-CTiON <br /> : � � � <br /> Premise Address: (.�/: �r f 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 /> Hermit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: -kk' n <br /> caeing. <br /> Driller' ��� he,cht <br /> Consultant AA . <br /> r <br /> Geologist ABOVE n <br /> COMPLETfOI,I CPN <br /> . - COMPLETION <br /> SPECIAL PERMIT INFO. q �S <br /> grout <br /> Distance to sewer line v�wu <br /> Domestic well on site - (y/n) tt• <br /> If yes, location and distance - ft- <br /> a <br /> SAMPLING dorotii y5 i <br /> sacien {I <br /> Holding Temperature _ <br /> yra'rvt Pack <br /> Method r <br /> Screening Method <br /> Tracking Sheet - (y/ n <br /> _. . ft. <br /> SPOILS <br /> Storage Method MATERIAIS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location Casing type <br /> g - � gl� ft. Screen K• <br /> Slot size <br /> GROUTING nags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios — Filter Pack type/size <br /> Installation Method Surge Black: - (y <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 k <br />