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WNITORING WELL INSTALLATION REPOR <br /> Date:a/Z/e-L CONSTRUCTION <br /> Premise Address: //y0 b• 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/cluistie Tox (circle one) <br /> Drilling Company: _ <br /> Driller: casing <br /> T height <br /> Consultant �'� <br /> Geologist <br /> 171— <br /> ABOVE-GROUND CHAS.STY-80X <br /> CONFLErION <br /> SPECIAL PERMIT INFO. GroundStriae COMPL–mCN <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) ft. <br /> If yes, location and distance - <br /> ft. <br /> ft. <br /> SAMPLING _- <br /> dorsi ::: c <br /> (/p ioCJcfl ?i'- <br /> Holding <br /> ^Holding Temperature T <br /> Method R"'°I pack <br /> .,. <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) -: <br /> 41IF <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/ Il ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> EH 29 29 Type of method <br />