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Y MONITORING WELL INSTALLATION REPORT <br /> Date:_ }�,�� �7 CONSTRUCTION <br /> Premise Address: 1004._ Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to)~� <br /> Bentonite (from) (to) <br /> Inspector; . Grout (from) {to) <br /> Drilling rig type - <br /> Permit No. Auger O.D. LD. <br /> Completion- Stove pipe/christie box (circle one) <br /> Drilling Company; <br /> Driller: casing. <br /> • _ _ �� height . <br /> Consultant, <br /> Ge <br /> Gin <br /> • ABOVE-GRC?UNG CHRZ Y-Box <br /> DO W LEMN coM.PL_=noN <br /> SPECIAL PERMIT INFO. Ground StAa-c* <br /> Distance to sewer line gtcut <br /> Domestic well on site,- {y/ri) <br /> If yes, location and distance- - <br /> ' tt. <br /> SAMPLING _— o <br /> rlat'.4,� �� C <br /> &ocfcn w{ <br /> Holding Temperature <br /> Method <br /> Screening Method �- <br /> Tracking Sheet (y/n <br /> Storage Method MATERIALS EVEI.OPMENT <br /> Conta.tnination Noted - [y/n) <br /> Storage Location Casing type <br /> Blank ft. Screen fT• <br /> Slot size <br /> G. ROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water _ rt - _ Bags sand/gravel <br /> MIX Ratios Filter Pack type/size <br /> 40staliation Method, - -- Surge Block: - (y/n ) <br /> Quantity Installed Discussed with geologist: - (y/n ) <br /> Type of method <br /> EH 2929. . <br />