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`MONITORING WELL INSTALLATION REPoKIr <br /> Date: 916100 CONSTRUCTION <br /> Premise Address: m Total Depth <br /> Well No.: MSV L— Screen Length (from) (to) <br /> 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 Company: Completion - Stove pipe/clu-istie box (circle one) <br /> Driller: <br /> casing <br /> height <br /> Consultant Crual., gyp► <br /> Geologist <br /> ABOVE-GROUND CIiFis.StY-BOX <br /> t�A�PLETiON COMPLETIONSPECIAL PERMIT INFO. G=nd Suriact <br /> Distance to server line gram <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - (t. <br /> p V <br /> SAMPLING = o <br /> sloro i :r _ <br /> ioc <br /> Cn <br /> _ <br /> Holding Tempe store U <br /> Method QA, va Pack <br /> Screening Method _ <br /> Tracking Sheet - (y/ n ) { <br /> ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) <br /> Storage Location Casing type <br /> Blank fL Screen ft. <br /> Slot size <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/ ri) <br /> SH 29 29 Type of method <br />