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MONITORING WELL INSTALLATION REPORT <br /> Date: I o CONSTRUCTION <br /> Premise Address: Total Depth .67 <br /> Screen Length (from) (to) S <br /> Well No.: rn Filter Pack (from) 33 (to) 5 <br /> Bentonite (from) 31 (to) _ <br /> Inspector: Grout (from) (to) 31 <br /> Drilling rig type _ <br /> Permit No. Auger O.D. I.D. <br /> OC} t Completion- Stove pip- e o (circle one) <br /> Drilling Company:_ <br /> Driller: casing <br /> - C height <br /> Consultant <br /> Geologist 11_ _qT <br /> ABOVE-GROUND <br /> COMPLETION C#iFi M_BOX <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line Grp <br /> Domestic well on site - (y/ n } 3 <br /> If yes, location and distance - 33 <br /> n• <br /> — m <br /> — m <br /> SAMPLING o <br /> slotted _ d <br /> &a on <br /> Holding Temperature <br /> Method _ ¢r"pack <br /> Screening Method => <br /> Tracking Sheet - (y/n} �� <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y rn) \/ <br /> Storage Location Casing type cert <br /> Blank_ -2, ft. Screen ft. <br /> Slot size -' ID <br /> Bags cement c j <br /> Buckets bentonite <br /> Depth 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/n ) <br /> EH 29 29 Type of method <br />