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MONITORING WELL INSTALLATION REPORT <br /> Date: �� I2 I t CONSTRUCTION <br /> Premise Address:1Total Depth <br /> 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/cliristie box (circle one) <br /> Drilling Company: <br /> Driller: _„_ casing <br /> height <br /> Consultant <br /> Geologist •— <br /> ABCVE-GACUND CHRtM43OX <br /> COMPLETION CC*APLE71CN <br /> SPECIAL PERMIT INFO. C3round Su lac# <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - (y/ n ) ft. <br /> If yes, location and distance - ft. <br /> ft. <br /> SAMPLING <br /> secricn <br /> Holding Temperature = gave POCK <br /> Method = <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> f1- <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios 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 /> i' <br />