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MONITORING WELL INSTALLATION REPORT <br /> Date: k- 9� CONSTRUCTION <br /> Premise Address: �i Total Depth <br /> n Screen Length (from) (to) <br /> Well No.: C/�0 -S 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/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height \ - <br /> Consultant T MPTA7/419 T <br /> Geologist Ll� ABOVE-GRCUND <br /> COhrFL_�TfON Ct�itSiY-SOX <br /> GO#MPL—=TICN <br /> SPECIAL PERMIT INFO. Ground Surfxs <br /> proem <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - ft. <br /> ft. <br /> ."a a <br /> n= M <br /> SAMPLING tloroi -_ <br /> soccicn <br /> Holding Temperature _ <br /> Q'iY4I Y'^" <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 <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 />