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MONITORING WELL INSTALLATION REPORT <br /> Date: /0-5-A13 CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. L� =-�-� 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: �cz,�,,' <br /> Driller: casing <br /> he=ght <br /> Consultant f f] IV <br /> 6' -GEWT <br /> Geologist VA,i A°" o <br /> ABOVE-G RCUND C.XR*TY-SOX <br /> OOWFLETfON GPMPLc'T1CN <br /> SPECIAL PERMIT INFO. Ground Svlacs <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - ft, <br /> ft. <br /> v o <br /> r <br /> SAMPLING iloroi _ <br /> 0 <br /> socicn <br /> Holding Temperature <br /> _ ¢-ave iaac <br /> Method <br /> r. <br /> Screening Method <br /> Tracking Sheet - (y/ n ) _ <br /> ft. = tt. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination 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 wateP� Bags sand/gravel <br /> Mix Ratios _ Filter Pack type/size <br /> installation Method Surge Block: - (y/n) <br /> Quantity Installed Discussed vrith geologist: - (y/ n) <br /> Type of method — <br /> EH 29 29 <br />