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MONITORING WELL INSTALLATION REPUttT <br /> Date: � � <br /> 03 CONSTRUCTION <br /> Premise Address: Y '\� ` Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. Grout (from) (to) <br /> P .Drilling rig type <br /> Permit No. <br /> Auger O.D. I.D. <br /> Completion - Stove pipe/chrisde box (circle one) <br /> Drilling Company: --rev <br /> casing <br /> Driller: —;F height <br /> Consultant <br /> Geologist Aj0_vE-GRCUND <br /> 0O WP LEtfON G�+R:STY�30X <br /> COt�tPL_�T1CN <br /> ---° <br /> SPECIAL PERMIT INFO. Ground Suiaas <br /> p art <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - ft• <br /> C <br /> O <br /> SAMPLING tlor.�i = 3 <br /> :ocicn <br /> Holding Temperature <br /> Method = —_ <br /> Screenin;Method —" <br /> Tracking Sheet - (y/n) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) Casinlbentonit <br /> Storage Location Blankfr. Screen fr <br /> Slot s <br /> GROUTING Bags <br /> BucknitDepth to water Bags avMix Ratios a Filterp /sizeInstallation ethod Surg (y/n) <br /> Quantity Installed Discugeologist: - (y/ n — <br /> Typeod <br /> EH 29 29 <br />