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MONITORING WELL INSTALLATION REPORT <br /> Date: 11 �61 CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: / Filter Pack (from) (to) <br /> Q Bentonite (from) (to) <br /> Grout from) (to) <br /> Inspector. a rig type <br /> lL Drillin e <br /> Permit No. Auger O.D. _ I.D. cr <br /> Completion - Stove pipe/cluistie boz (circle one) <br /> Drilling �Company: <br /> � casing <br /> (2'-Drillef: height <br /> Consultant <br /> Geologist t <br /> ABOVE-GFICUND , <br /> t COYPLETiCN C�nCN <br /> SPECIAL PERMIT INFO. " Stzf'n .-� <br /> prat ` <br /> Q� Distance to sewer line <br /> ZT - <br /> \ Domestic well on site - (y/ n) II. <br /> If yes, location and distance - ft. <br /> .lctr—tt. <br /> - O <br /> SAMPLING alorod <br /> socicn —_ <br /> Holding Temperature <br /> Method =_ _ <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) K P UT-, r� 6 <br /> Storage Location Blank tYPe aft. Screen h• <br /> Slot size � <br /> GROLITING Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel I a FF/ 1 bd <br /> Depth to water Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/1 0.0- <br /> CTI)jf7L_vrnbl <br /> Quantity Installed Discussed with geologist: - / n) <br /> Typq of mctltod� <br /> EH 29 29 <br />