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MONITORING WELL INSTALLATION REPORT <br /> Date: �/� /D/ CONSTRUCTION <br /> ��ya Total Depth S� <br /> Premise Address: I Screen Length (from) r;b (to) <br /> �,✓Yn/ 1� Filter Pack (from) 7 � (to) ` ' <br /> Well No.: Bentonite (from) —,, :R (to)z 5 <br /> Grout (from) (to) <br /> Inspector. Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> DrillerG� height <br /> IV <br /> Consultant 41M T <br /> Geologist _ AgovE-GPCIJND at RZTY-box <br /> COMPLETION ccMPL-=ncN <br /> Ground SLA act <br /> SPECIAL PERMIT INFO. <br /> greet <br /> -- <br /> Distance to sewer line <br /> 'Z <br /> ft. <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - � • <br /> �� OC <br /> SAMPLING N�fP soc'cn <br /> VA 0'r'^".^� <br /> Holding Temperature <br /> Method <br /> Screenino Method <br /> Tracking Sheet - (y/ n) <br /> tt. <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method It <br /> Contamination Noted- (y/ n) Casing type �'�� �. <br /> Storage Location Blank k, ft• Screen— <br /> Slot size 0 .0(0 <br /> Bags cement <br /> GROUT_ iNG Buckets bentonite <br /> �� �K �� Bags sand/gravel_ y ►0 0 <br /> Depth to water Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/ 11) <br /> Installation Method Discussed with geologist: - (y/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />