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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: ,+�' �c Filter Pack (from) (to) <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: ���'�,� '���1,� <br /> Driller: / E casing <br /> 177T height <br /> Consultant- E �if � If <br /> 7/4 T <br /> Geologist �/�� �°,�.9�-"�'" -- <br /> ABCVE-GRCUNO CNA15'TY-80X EW <br /> COMPLrcT{ON COMPLEnCN <br /> SPECIAL PERMIT INFO. Ground Sumacs 10 <br /> Distance to sewer line grout <br /> Domestic well on site - ( y/ n ) . <br /> If yes, location and distance - - <br /> Y <br /> ti•• � O <br /> SAMPLING �loi:si <br /> socticn =_ <br /> Holding Temperature <br /> Method — F <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. <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 />