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MONITORING WELL INSTALLATION REPORT <br /> Date: - 1 �`6I f7 5� CONSTRUCTION <br /> Premise Address: Total Depth <br /> Well No.: <br /> Screen Length (from) (to) <br /> �+Ll—�fI 5A K 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 /> Drilling Compan <br /> Completion - Stove pipe/dirisde box (circle one) r <br /> y; <br /> Driller: S? <br /> Consultant <br /> Geologist <br /> grout <br /> SPECIAL PERMIT INFO. seal <br /> Distance to sewer line eft. <br /> Domestic well on site .- (y/n ) <br /> If yes, location and distance - <br /> gravel pack <br /> n. <br /> SAMPLING <br /> seal <br /> Holding Temperature <br /> Method J3Lft- <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> { gravel pack <br /> SPOILS <br /> 3 S ft.. 36 <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Cont4mination Noted - ( y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mig Rados 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 />