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f ' ' MONITORING WELL INSTALLATION REPORT <br /> CONSTRUCTION <br /> Date: � �`•' ��n <br /> �j �fo Total Depth <br /> Premise Address: Screen Length (from) (to) <br /> / u Filter Pack (from) (to)- __=�- <br /> Well No.: U Bentonite (frorn) (to) <br /> Grout (from) (to)! <br /> Inspector. Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/cluisde box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: he-ght <br /> Consultant 7//,F6 <br /> T <br /> Geologist r ABOVE-GFICUND C IMM-BOX <br /> oowFLEr N <br /> Ground surtacs <br /> SPECIAL PERMIT INFO. <br /> grout <br /> Distance to serverIZ- <br /> Domestic well on site - (y/n} �- <br /> If yes, location and distance - <br /> } <br /> ra � <br /> a <br /> SAMPIJNG est X on a <br /> r 71 19; . <br /> Holding Temperature rr <br /> Ay' _ <br /> Method <br /> Screening Method _ <br /> Tracking Sheet - {y/ n) = — <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method <br /> Contamination Noted- (y/ n) Casing type <br /> Storage Location gl ft. Screen � <br /> Slot size <br /> Flags cement <br /> GROUTING Buckets bcntonite <br /> ` Bags sand/gravel <br /> Depth to water Filter-Pack type/size <br /> Mix Ratios ` - Surge Block: - (y/ n > <br /> Installation Method Discussed vAth geologist; - (y! n } <br /> Quantity Installed Type of method <br /> EH 29 29 <br />