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ONITORING WELL INSTALLATION REP._i <br /> Date: CONSTRUCTION <br /> Premise Address: 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. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: 7- casing <br /> height <br /> Consultant <br /> Geologist A°avTr G�CUND <br /> F.�I_ET{ON C1 -30X <br /> CO <br /> c:or.+PmcN <br /> SPECIAL PERMIT INFO. Ground Sul act <br /> proc.K <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) _ ft. <br /> If yes, location and distance - ft. <br /> _ M <br /> O <br /> SAMPLING <br /> Holding Temperature <br /> Q-aw1 <br /> Method <br /> Screening Method = <br /> Tracking Sheet - ( y/ n) _ <br /> tt. <br /> SPOILS <br /> Storage Method MATERIALS/DEVEI.OPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location _ Casing type - ft <br /> Blank ft_ Screen <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 /> -4pstallation Method Surge Block: - ( y/ n ) <br /> Quantity Installed _ Discussed vAth geologist: - (y/ n ) <br /> Type of method„ — <br /> EH 29 29 <br />