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MONITORING WELL INSTALLATION REPMT <br /> Date: CONSTRUCTION <br /> Premise Address: Total 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/christie box (circle one) <br /> Drilling Company: cas_ <br /> ng <br /> Driller helght <br /> i e�.ght <br /> Consultant If <br /> 7, <br /> Geologist T <br /> ABOVE-GROUND CHRZry- ox <br /> CONPL-7)ON COMPLEMN <br /> SPECIAL PERMIT INFO. C3=nd Suiset "T"""'"""�'�""'"'^� <br /> Distance to sewer line grant <br /> Domestic well on site - ( y/ n ] ft. <br /> Ii yes, location and distance - _ <br /> .ft. <br /> N <br /> 5w• <br /> 0 <br /> SAMPLING �tlarai <br /> aocicn — <br /> Holding Temperature gnva Pack <br /> Method <br /> Screening Method — <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type <br /> BIank ft. Screen <br /> Slot size <br /> GROUTING Bags cement---- - -- T� - <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 /> Eli 29 29 <br />