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MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> CONSTRUCTION <br /> � 7� / "� � ��� �'" 4 Total Depth`I`'�O <br /> Premise Address: <br /> Screen Length (from) (to) <br /> — <br /> Filter�S3� Filter Pack (from) (to) <br /> Well No.: 7po Bentonite (from) (CO) <br /> � �� . Grout (from) (to) <br /> Inspector. Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. T / Completion - Stove ipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: height <br /> Consultant ( co T <br /> r/1'1 6 <br /> Geologist ""ti Aj! vF-GRCl1ND C4-nZTY-BOX <br /> CO tiff L_ET C N COMPL.�T1 C N <br /> Ground Sul <br /> SPECIAL PERMIT INFO. <br /> Distance to sewer line _.ft. <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - <br /> � � C <br /> SAMPLING <br /> o� <br /> Holding Te perature - —_ <br /> Method wtsl oA� _ <br /> Screening Method - — <br /> Tracking Shcet - (51 <br /> n ) <br /> SPOILS <br /> Storage Method <br /> NIR MATERIALS �OP=ENT <br /> Contamination Noted - (y/ n ) Casing type <br /> Storage Location Blank ft. Screen ft. <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets ben nite <br /> Bags sand/Favel <br /> Depth to water- U Filter Pack,c/size <br /> Mix Ratios C Surge Block: - ( y <br /> Installation Method Discussed with geologist: - (y/ n ) <br /> Quantity Installed Type of rnethod <br /> EH 29 29 <br />