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I MONITORING WELL INSTALLATION REPORT <br /> 'a 6� CONSTRUCTION <br /> Date : L <br /> Premise Address: n W O &A& Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> f/ Bentonite (from) (to) <br /> Inspector. �` �`" � Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> � Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling Company: <br /> Driller. �� ffff!!!!✓✓✓✓ � casing <br /> height <br /> Consultant V <br /> Geologist <br /> ABOVEwGRCUND ISTY30X <br /> CChFLETION CcMPLEMON <br /> SPECIAL PERMIT INFO. ® — Cho nd Svrtan <br /> Distance to sewer line _ Qty <br /> Domestic well on site - ( y - Ito <br /> If yes, location and distance - <br /> fft. <br /> t <br /> — a <br /> SAMPLING doCad <br /> sxion —_ <br /> Holding Temperature - F <br /> _ Method Z. _ <br /> Screening Method Tracking Sheet - ( y / n ) LoUijfi. <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 bentonire <br /> Depth to water Bagssand/gravel <br /> Mix Ratios e 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 /> i <br />