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MONITORING WELL INSTALLATION REPORT <br /> Date: Zf CONSTRUCTION <br /> Premise Address: ` ' 1 Total Depth <br /> Screen Length (from) (to)_ <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: J��" " - ' 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 /> casing <br /> Driller: <br /> he:.ght <br /> Consultant <br /> 7//, <br /> Geologist A; -GRCUND <br /> CO W G..RSON CVAPUMON <br /> C�3:SrY-30X <br /> SPECIAL PERMIT INFO. Ground Sul <br /> gra.t <br /> Distance to sever line <br /> Domestic well on site - ( y/ n <br /> if yes, location and distance - . <br /> ft. <br /> m <br /> - P <br /> C <br /> SAMPLING <br /> Holding Temperature GnY4�+- <br /> Method <br /> Screening Method _ <br /> Tracking Sheet - [ y/ n <br /> a. <br /> ft. <br /> SPOILS <br /> Storage Method q MATERIALS/DEVELCIPNIENT <br /> Contamination Noted - [y/ n } <br /> ,Storage Location Casing type <br /> Blank ft. Screen h <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 va4{ ( bl <br />