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MONITORING WELL INSTALLATION REPORT <br /> CONSTRUCTf ON <br /> Date: <br /> Total Depth <br /> premise Address: screen Length (frorn) CEO) <br /> Filter Pack (from) CEO) <br /> `',fell No.: ; Bentonite (from) (to) <br /> Grout! (fram) (to) <br /> Inspector, Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/cluisde box (circle arse) <br /> Drilling Comp2-ny: <br /> Driller: '�— hes5ht <br /> Fl[ <br /> Consultant <br /> Geologist ASO`=-GRCkNO <br /> COWLEMN <br /> SPECIAL PERMIT INFQ. <br /> • _ IIrcc.: <br /> Distance to ;elver Iine <br /> Domestic zvell on site - (y/ n ) <br /> If yes, location and distance - �r <br /> ' a <br /> SAMPLING so-cicn _ <br /> rdPwX <br /> Holding Temperature - <br /> Method t .r <br /> Screenim,Method <br /> Tracking Shcet. y nh. <br /> SPOILS <br /> , _ MATERiALS/D�E.OPN[ENT <br /> Storage Method t <br /> Contamination Noted (y/ n} v Casing type ft. <br /> Storage location Blank fc Sween <br /> Slot size <br /> Bags cement <br /> GRoU-nNG Puckcts bcntonite <br /> Bags sand/gra�el <br /> Depth to water - Filter pack typc/size <br /> Miz Ratios Surge Block: - (y/n) <br /> ipstallation Method Discussed With geologist: - {y/n} <br /> Quantity Installed Type.of rncthod <br /> EH 24 29 _ - <br /> y w <br />