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MONITORING WELL INSTALLATION REPMT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Wel] No.: Filter Pack (from) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. _ I.D. <br /> Drilling Company: Completion - Stove pipe/cliristie box (circle one) <br /> Driller: rasing <br /> height <br /> Consultant '!° <br /> Geologist _ T <br /> ABOVE-GROUND <br /> 0C&FLEr{CN C-S TY-80X <br /> SPECIAL PERMIT INFO. COA4PLE7CN <br /> Ground Surfw* <br /> Distance to sewer line grcut <br /> Domestic well on site - (y <br /> If yes, location and distance - ft• <br /> ft. ft. <br /> • r <br /> SAMPLING o <br /> aEor.� c <br /> &mien <br /> Holding Temperature <br /> .Method gavel pads <br /> Screeninb Method _ <br /> Tracking Sheet - ( y/ n ) <br /> ,--.... ..�fi• fL <br /> SPOILS <br /> Storage Method MATERIALS FVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank fr. Screen h, <br /> Slot size <br /> GRG[TCING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios ___ Filter Pack typesize <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of r ediod <br /> EH 29 29 <br />