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MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> CONSTRUCTION <br /> Premise Address: ,'--,, <br /> Total Depth <br /> Well No.:- PA b6r j Screen Length (from) <br /> Filter Pack (from) (to)�_ <br /> Inspector. j ;� A rCy? % Bentonite (from) (to)_-- <br /> Grout (from) (to) _ <br /> Permit No._ 0 Drilling rig type ------ <br /> Auger O.D. I.D. <br /> Drilling Company ;, , , a Completion - Stove pipe/christie box (circle one) <br /> Driller: <br /> casing <br /> Consultant height <br /> Geologist <br /> A.iCVE-GacuNO <br /> CnIFL.�TChl �LSTY-3ox <br /> SPECIAL PERMIT INFO. COMPL. MCN <br /> — Ground Surtaca <br /> Distance to sewer line <br /> Domestic well on site (Y/ n <br /> - grout <br /> ) <br /> If yes, location and distance - <br /> i' f t. <br /> SAMPLING <br /> •foci c <br /> Holding Temperature soden = <br /> Method <br /> Screening Method _ <br /> Tracking Sheet - <br /> OILS 4'_ <br /> SPfI. <br /> Storage Method <br /> Contamination Noted - (y/n ) MATE RIALS/pEVE[OPMENT <br /> Storage Location <br /> Casing type <br /> Blank '. , ft. Screen_ <br /> GROUTING Slot size <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios Bags sand/gravel <br /> Installation Method Filter Pack type/size <br /> Quantity Installed Surge Block: - (y/ ti ) <br /> Discussed with geologist: - (y <br /> EH 29 29 Type of method <br />