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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from)' (to) <br /> Well No.: Filter Pack (from) <br /> (to) <br /> Bentonite" (from) (to) <br /> Inspector: Grout (from) <br /> (to) <br /> Dulling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: Completion- Stove pipe/christie box (circle one) <br /> Driller: casing <br /> height <br /> Consultant ' <br /> Geologist <br /> ABOVE-GROUND <br /> CO&FLEf ON CNRI57743OX <br /> SPECIAL PERMIT INFO. COMPLEtON <br /> Ciruund Swiace <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - ft. <br /> ft. _ <br /> ft. <br /> �r <br /> e <br /> SAMPLING *' o <br /> ax�an ;: <br /> Holding Temperature <br /> Method ' <br /> Screening Method <br /> Tracking Sheet (y/n) <br /> SPOILS <br /> t <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location Casing type <br /> Blank ft. Screen $. <br /> GROUTING Slot size <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method __.-Surge._$losk:_(_y/_n_) _ <br /> Quantity Insialled Discussed with geologist: - (y/n) <br /> EH 29 29 Type of method <br />