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MONITORING WELL INSTALLATION REPORT <br /> Date:sqZd Z CONSTRUCTION <br /> Premise Address: `JC( /STµ' /+'( �itt.1/`� Total Depth Y J <br /> �C _ I Screen Length (from) (to) <br /> Well No.:_ J Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> ' ) Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: _.,._ casing <br /> he_ght <br /> Consultant I <br /> V111 <br /> II <br /> Geologist q-,deb -- <br /> ABOVE-GRCUND <br /> COhSPI._�7fON ChAtS'7Y-B0X <br /> COMPI.EMN <br /> SPECIAL PERMIT INFO. Sufacs <br /> Distance to sewer line (� orCut <br /> Domestic well on site - ( y/ n ) ft. <br /> �.� <br /> If yes, location and distance - <br /> ft ft. <br /> = m <br /> O <br /> SAMPLING <br /> Holding Temperature <br /> Method = <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) UE�_[U- <br /> ft. ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size 0.DI 0 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags 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 />