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MONITORING WELL INSTALLA'T'ION REPORT <br /> Date: `� CONSTRUCTION <br /> S C? Total Depth_ <br /> Premise Address: to <br /> Screen Length (from) (to) <br /> Well No.: �L-' Filter Pack (from) - (to) <br /> i�-- <br /> Bentonite (from) ,'5 (to) <br /> Inspector. �� "v Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> _. Completion - Stove pipe/cl istie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: <br /> I height <br /> Consultant t <br /> Geologist ABOVE-GROUND <br /> CCB.VLETCN C, (Ot�iPt~=LPI 30X <br /> C �-71CN <br /> SPECIAL PERMIT INFO. Grctund Sal acs <br /> prcut <br /> Distance to sewer line <br /> Domestic well on site - ( y/ n ) /ft. <br /> If yes, location and distance - � � ft. <br /> g t. <br /> M <br /> C <br /> O <br /> SAMPLING ilorn.f <br /> Holding Temperature = g'Y1W Pack <br /> Method ak, = <br /> Screenin;Method _ <br /> Tracking Sheet - ( y/ n ) <br /> J ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) Casing <br /> Storage Location type <br /> l <br /> Blank ft- <br /> ft- Screen i <br /> Slot size L� <br /> GROUTING Bags cement <br /> Buckets bentonite - <br /> ` * Bags sand/gravel <br /> Depth to water -► — <br /> Mix Ratios Filter Pack type/size -- <br /> Installation Method Surge Block: - ( y/ ii ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of metliod <br /> EH 29 29 <br />