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MONITORING WELL INSTALLATION REPORT <br /> Date:_ S/S//Q CONSTRUCTION <br /> T / <br /> Premise Address: L/��$ �^ �L� Total Depth � l <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: <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist —W <br /> ABOVE-GROUND <br /> COMPLETION CHRMIY-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface 7— <br /> Distance to sewer line Grp <br /> Domestic well on site - (y/ n ) tt <br /> If yes, location and distance - n <br /> o <br /> SAMPLING <br /> alottad Z,..: — c <br /> aeon <br /> Holding Temperature <br /> Method ' = 7'VW Pack...' <br /> Screening Method � _ - <br /> Tracking Sheet - (y/n) ' <br /> ft. <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 Surge Block: - (y/n ) <br /> Quantity Installed Discussed with geologist: - (y/n ) <br /> Type of method <br /> EH 29 29 <br />