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MONITORING WELL INSTALLATION REPORT <br /> CONSTRUCTION <br /> Date: <br /> Total Depth <br /> Premise Address: Screen Length (from) (to)_.- <br /> Filter Park (from) <br /> to �— <br /> Well No.: -- Bentonite (from) _(to)_— <br /> Grout (from) (to)� <br /> Inspector: Drilling ng tYPe I.D. <br /> Auger O.D. <br /> Permit No. — Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: --— <br /> —�r--1 _ casing <br /> Driller: -- � 4 height <br /> _WW <br /> Consultant �r <br /> 1 :ZIA <br /> Geologist ABOVE-GROUND �,i'- -80X <br /> CCWLET}ON COMPLETCN <br /> f3=rd Surface <br /> SPECIAL PERMIT INFO. grout <br /> Distance to sewer line — n• <br /> Domestic well on site - (y/ n ) _—- - fl. <br /> If yes, location and distance - — ft 71— <br /> cc <br /> C <br /> C <br /> iIOCCBd <br /> SAMPLING <br /> ax�On <br /> gf1Y61 t""" <br /> Holding Temperature --- __ <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) —' ft. <br /> SPOILS <br /> TERIALS fD LOPMENT <br /> Storage Method <br /> Contamination Noted (Y/ n) Casing type ft. <br /> Storage Location <br /> -- Blank ft. Screen <br /> Slot size <br /> Bags cement-------- <br /> GROUTING <br /> ementGROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water -- Filter Pack type/size <br /> Mix Ratios Surge Block: - ( Y/ n ) <br /> Installation Method---------------- Discussed with geologist: - (y/ n) <br /> Quantity Installed -- Type of method <br /> EH 29 29 <br />