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MONITORING WELL INSTALLATION REPORT <br /> Date:�/�� CONSTRUCTION <br /> Premise Address:_oZSy/ r)aar.,ib-j" 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 /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> Driller: casing <br /> height <br /> Consultant_ A, Z <br /> Geologist–&Xw, <br /> ABOVE-GROUND <br /> COWPLETZN CHRM Y-SOX <br /> SPECIAL PERMIT INFO. Ground Sexy COMPLETION <br /> Distance to sewer line Grp <br /> Domestic well on site - (y/n ) <br /> If yes, location and distance - n• <br /> . ft ft. <br /> C <br /> SAMPLING <br /> tichad — c <br /> sac4on — <br /> Holding Temperature <br /> Method — �"'al pack <br /> Screening Method } <br /> Tracking Sheet - (y/n) ' <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 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/ n ) <br /> Type of method <br /> EH 29 29 <br />