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MONITORING WELL INSTALLATION REPORT <br /> Date: D CONSTRUCTION <br /> Premise Address: >f..?1A*N-0 9- Total Depth <br /> ��,,��"" pppScreen Length (from) (to) <br /> Well No.:C, Or/�0 - 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 /> Driller: casing <br /> height <br /> Consultant �K <br /> Geologist n L <br /> ABOVE-GROUND <br /> 00&FLET10N CF- -$OX <br /> COMPLEPtET10N <br /> SPECIAL PERMIT INFO. Ground Su lws <br /> Distance to sewer line Grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - <br /> ft. <br /> SAMPLING <br /> �lottsd w: � <br /> ascton <br /> Holding Temperature Y„ <br /> Method _ v" P <br /> ack <br /> Screening Method : = <br /> Tracking Sheet - (y/n ) <br /> .a: <br /> it. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <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 2 Surge Block: - (y/n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />