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MONITORING WELL INSTALLATION REPORT <br /> Date: �'" CONSTRUCTION <br /> Premise Address: 1 ti P Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from)—(EO)- <br /> Inspector- <br /> from) (to)Inspector !d( n '�P Grout (from) (to) <br /> Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> �S casing <br /> Driller: // height <br /> Consultant Af <br /> Geologist 11—el— ABCVE-GRCUND <br /> COWLE7CN CCS L--MOAiWPLE71CN <br /> SPECIAL PERMIT INFO. Stztac� �� <br /> grcut <br /> Distance to sewer line 1 <br /> Domestic well on site - ( y/ n) <br /> If yes, location and distance - tt <br /> )� �C ft. — <br /> __ m <br /> O <br /> �Ior.Ai � <br /> SAMPLING tocicn _ <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) Casing type X, <br /> FVI( <br /> Storage Location Blank / fr. Screen � ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Filter Pack type/size <br /> Mix Ratios <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br />