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MONITORING WELL INSTALLATION REPORT <br /> Date: `��� 1 CONSTRUCTION <br /> Premise Address: //go w l�•.,,,.�,,. �• w (� 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: casing <br /> T height <br /> _ T <br /> Consultant �^ -•� t� _ <br /> Geologist •- <br /> A80VE-G8C4JND C4-S*TY480X <br /> CONFLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Satace <br /> Distance to sewer line grout <br /> Domestic well on site - ( y/ n ) ,ft, <br /> If yes, location and distance - ft- <br /> ft. <br /> O <br /> SAMPLING Z <br /> saricn �•• — <br /> Holding Temperature — Ravi Pack <br /> Method <br /> Screenin; Method <br /> Tracking Sheet - ( y/ n ) _— <br /> tt. = fL <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location e Casing type <br /> Blank ft. Screen fr. <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 />