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MONITORING WELL INSTALLATION REPORT <br /> Date:-- <br /> /tea CONSTRUCTION <br /> 0�0 / <br /> Premise Address: Total Depth <br /> �o Screen Length (from) (to) <br /> Well No.: ! Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Coomnnpany: <br /> Driller: (� Sf CpiL4� �_ _ casing <br /> g ( height <br /> Consultant ,1/0�'',��A�'��J <br /> Geologist 1 A4;ti - T <br /> ABCVE-GACUND CtR&M-BOX <br /> COWLETICN COMPLEI ICN <br /> SPECIAL PERMIT INFO. Crourd Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) ft. <br /> If yes, location and distance - ( n /IpM� <br /> w <br /> _ o <br /> C <br /> SAMPLING glored = S <br /> N/ .Q,Icn = <br /> Holding Temperature = 71y9i Pack <br /> Method <br /> Screening Method r <br /> Tracking Sheet - ( y/ n ) <br /> ft. ft. <br /> SPOILS CRF <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) I L �" -1 A , <br /> Storage Location Casing type �11 L SS w <br /> Blank ft. Screen ft. <br /> Slot siu , 74 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water / 7 Bags sand/gravel <br /> Mix Ratios �+. e _ 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 />