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MONITORING WELL INSTALLATION REPORT <br /> Date: z CONSTRUCTION <br /> Premise Address: zzIA a„� Total Depth 0 <br /> Well No.: Screen Length (from) ,5- <br /> Filter <br /> Filter Pack (from)__ If 5 (to) <br /> Inspector: Bentonite (from)_ 4. f (to) <br /> Grout (from) <br /> Permit No. Drilling rig type <br /> Augcr O.D. I.D. <br /> Drilling Company: Completion- Stove pipe/christie box (circle one) <br /> Driller: A AA <br /> casing <br /> Consultan � height _WT <br /> Geologist <br /> ABCY>_•GACUND <br /> COh�Pt...-=TION �Mly-BOX <br /> SPECIAL PERMIT INFO. CDM t_=nCN <br /> G=rd Sedate <br /> Distance to sewer line <br /> Domestic well on site - /n) Qrocrt <br /> If yes, location and ' tante - <br /> !1 r <br /> SAMPLING <br /> �IoC.ai :•' c <br /> Holding Temperature soc7crs <br /> Method <br /> :+• STYY01 F'a1:3C <br /> Screening Method ; — <br /> Tracking Shcet (y/ n ) <br /> ..ft. f1. <br /> SP-FOILS <br /> Storage Method MATERIALS EVELOPMENT <br /> Contamination Noted - ( n <br /> Storage Location �t <br /> Casing type <br /> Blank fL Screen �" fL <br /> GR` p�NG Slot size .01-0 <br /> Flags cement <br /> Depth to water Buckets bentonire <br /> Mix Ratios Bags sand/gravel <br /> N Filter Pack type/s ze <br /> In.5ta]Iadon Method Surge Block: - n ) <br /> Quantity Installed Discussed with geologist: - (y 49 <br /> EH 29 29 Type of riethod <br />