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MONITORING WELL INSTALLATION REPORT <br /> �K I� CONSTRUCTION <br /> Date: <br /> Total Depth <br /> Premise Address: Screen Length (from) <br /> Filter Pack (from) (to) <br /> Well No.: �"'� ftA' Bentonite (from) (to) <br /> Jl Grout (from) (to) <br /> Inspector. Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller• height <br /> Consultant <br /> Geologist ABOVE-G R C:UN D Ct�i:STY�30X <br /> CONVLETfON CO tPLEMON <br /> Ground Suiacs — <br /> SPECIAL PERMIT INFO. pra.K <br /> Distance to sewer line _.ft. <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - <br /> V` » <br /> � C <br /> O <br /> tlorai _ 2 <br /> SAMPLING soccicn <br /> VnYS1 Pack <br /> Holding Temperature =" _ <br /> Method ? ' <br /> Screening Method _ <br /> Tracking Sheet - (y/ n) = tt• <br /> SPOILS <br /> MATERIALS <br /> /DEVELOP MENT <br /> Storage Method <br /> Contamination Noted - (y/ n) Casing type ft. <br /> Storage Location Blankfc. Screen <br /> Slot size <br /> Bags cement <br /> GROUPING Buckets bentonite <br /> f�p' Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/n) <br /> ipstallation Method Discussed with geologist: - (y/ n) <br /> Quantity Installed Type of rnctliod <br /> EH 29 29 <br />