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MONITORING WELL INSTALZ.ATION RE-°ORT <br /> CONSCRUGTION <br /> Date: <br /> ` �""� �� �� Total Depth (to) <br /> Premise Address: Screen Length (from) <br /> 2- �h cUS Filter Pack (from) (to) <br /> Well No.: Bentonite (from) (to) <br /> Grout (from) (to) <br /> Inspector. ti Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company <br /> casing <br /> Driller• _ �� height <br /> Consultant (t-off — ' <br /> Yl a --t 1�°pYE-G R CLJN D <br /> Caw LET f0N (;oN PLETtCN <br /> Cxcc:rd Sul act <br /> SPECIAL PERMIT INFO• pru.t <br /> Distance to sewer lineft. <br /> Domestic well on site = (Y/ n) tt. <br /> If yes, location and distance - <br /> _ o <br /> C <br /> ilac:.a-d <br /> SAMPLING socicn <br /> Holding Temperature ! <br /> t� <br /> Method = <br /> Screening Method : <br /> Sh - / n <br /> eet <br /> Tracking <br /> SPOILS <br /> M ATERI ALS/DEVEGOPMENT <br /> Storage Method <br /> Contamination Noted - (y/ n) Casing type f <br /> Storage Location Blank ft_ Screen <br /> Slot size <br /> Bags cement <br /> GROUTING <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> : - C Y/n) <br /> Miz Rados Surge Block <br /> installation Method Discussed vrith geologist: - (Y/ n <br /> Quantity Installed Type of method <br /> EH 29 29- <br />