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MONITORING WELL INSTALLATION REPORT <br /> Date: coNSTRUCTION <br /> Premise Address: y Total Depth <br /> —��� — Screen Length (from) (to) <br /> Well No.: � � .1� 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 Company: <br /> casing <br /> DrillerA �� height <br /> 1 <br /> Consultant <br /> Geologist ABOVE-GRCUND <br /> t�.�p LEf iON Ct�itSTY-30X <br /> Oq <br /> GOhiPt_mcN <br /> SPECIAL PERMIT INFO. Cirourd 5uixt <br /> Qroct <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) kft. <br /> if yes, location and distance - �- <br /> i K <br /> G <br /> O <br /> SAMPLING siorki <br /> ----— s acicn <br /> -Avot Pack <br /> Holding Temperature — <br /> AY• <br /> Screening Method — <br /> Tracking Shcet (y/ n) _; <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted- (y/n} Casing type <br /> Storage Location Blank Screen ft <br /> Slot size <br /> GRA G Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> y/n <br /> installation Method Surge Block: - { } <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of racchod <br /> EH 29 29 <br />