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MONITORING WELL INSTALLATION REPORT <br /> Date: 7G /� L CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: 1�( Ylb'� �^ Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> I � Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: W '��- <br /> Driller: cas ing <br /> height <br /> Consultant Qn/1 —WWT <br /> Geologist <br /> ABOVE-GROUND CtSR M-&Ox <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. / Ground Surface <br /> Distance to sewer line 1.w"1 grout <br /> Domestic well on site - (y/ ) <br /> If yes, location and distance - ft. <br /> ft. <br /> ft. <br /> a0. <br /> o <br /> SAMPLING atoned = B <br /> C saclon <br /> Holding Teu3perature <' <br /> Method ! ack <br /> : _ P <br /> rix = <br /> Screening Method PZ- <br /> Tracking <br /> Z <br /> Tracking Sheet - ,(Y'/ n ) _= <br /> tt. "� ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING 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/ n ) <br /> Type of method <br /> EH 29 29 <br /> s� <br />