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MONITORING WELL INSTALLATION REPORT <br /> Date: ` CONSTRUCTION <br /> Premise Address: _ Total Depth <br /> Screen Length (from) (to) <br /> Well No.: L-- " I A Filter Pack (from) (to) <br /> T Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. /9 T Auger O.D. I.D. <br /> h k) Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: -f-G <br /> Driller: casing <br /> height <br /> —CWT <br /> Consultant T7 T_ <br /> Geologist 6 LIM,, Alf' <br /> .~VE-GROUND CHR* Y-80X <br /> COMPLETION CONIPLEftON <br /> SPECIAL PERMIT INFO. GAJ round Surface <br /> Distance to sewer line ®rout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft. <br /> ft <br /> SAMPLING /_ clotted C <br /> Vsedon — <br /> Holding Temperature -- <br /> Method ®� t ' P , <br /> Screening Method — <br /> Tracking Sheet - (y/ n) ® :" <br /> ELL% '"� _ itit. <br /> SPOILS � d I D <br /> Storage Method MATERIALS/DEVELOPMENT (lbF� <br /> Contamination Noted - (y/ n) <br /> Storage Location sing type <br /> ' U Bl ft. Screen ft. <br /> Sl t size <br /> GROUTING `/ Ba cement <br /> / Bu�ckets bentonite <br /> Depth to water ® 1�'ags 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 />