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MONITORING WELL INSTALLATION REPORT <br /> j f <br /> f � <br /> Date: 7 CONSTRUCTION <br /> Premise Address:. / �� Total Depth <br /> Screei'16i <br /> Well No.: ��� J� Filter Pack (from) (to) <br /> (from) (to) <br /> l ) 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 /> / �� height <br /> Consultant-__7W <br /> Geologist <br /> ABOVE-GROUND <br /> CGMPLET1ON C� ms- Y-80X <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - <br /> CD i <br /> SAMPLING ted __ o <br /> rot .� � <br /> ►aeon �-"• — � <br /> Holding Temperatureval pack <br /> �. <br /> Method — <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: s <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 />