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MONI'T'ORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to)_— <br /> Bentonite (from) (to) <br /> dnspector. Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/clu-i.sde box (circle one) <br /> Drilling Company: <br /> Driller: <br /> casing <br /> height <br /> Consultant IFm V <br /> Geologist _. <br /> ABOVE-GR CUNDCOMPLEMN C�RSTY 30X <br /> CO�{r Lc'TICN <br /> SPECIAL PERMIT INFO. Cx-�rd Stsfscs <br /> Distance to sewer line flra.� <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - <br /> • <br /> v �• O <br /> M <br /> SAMPLING = c <br /> 0 <br /> sforQ-d <br /> socicn — <br /> Holding Temperature — <br /> Method <br /> Screening Method <br /> Tracking Shcet - (y/ n ) - <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location Casing type <br /> Blank ft. Screen <br /> Slot size <br /> GROUPING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Miz Rados Filter Pack type/size <br /> installadon Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed vrith geologist: - (y/ n ) <br /> Type of ractliod <br /> EH 29 29. . <br />