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MONITORING WELL INSTALLATION REPORT <br /> Date: S + CONSTRUCTION <br /> Premise Address: ��1 `T ! Total Depth <br /> Screen Length (from) ([o) <br /> Well No.: FilterTack (from) <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,, QL, <br /> Driller: casing <br /> he,ght <br /> .Consultant t}'r� <br /> Geologist <br /> ABOVE-GROUND cr�zsrf-aax ' <br /> ooNFLETMN <br /> co+'at_ncN <br /> SPECIAL PERMIT INFO. Card Sutacs <br /> Distance to sewer line Rz, <br /> gram <br /> Domestic well on site - (y/ n) It: <br /> If yes, location and distance - <br /> ° C <br /> 4 <br /> SAMPLING a1or.Ri s _ <br /> ;aticn <br /> Holding Temperature <br /> Method ° ` > <br /> Screening Method <br /> Tracking Sheet (y/n) - <br /> SPOILS -- — . ' •.,.:_ �1�� <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n <br /> Storage Location Casing type <br /> Blankft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> r Buckets bentonite <br /> Depth to water, -' Bags sand/gravel 7 1 o <br /> Mix Ratios Filter Pack type/size jcf <br /> 4pstalIation Method Surge Block: -0/xz ) <br /> Quantity Installed Discussed vrith geologist: - (�' / n) fl <br /> Type of method <br /> �. <br /> EH 29 29. <br />