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MONITORING WELL INSTALLATION REPORT <br /> Date: �/ ��/ �� CONSTRUCTION <br /> Premise Address: " "Y �� r - Total Depth <br /> Screen Length (from) Cto) <br /> Well No: Filter Pack (from) (to) <br /> Bentonite (from) (50) <br /> to) <br /> Grout (from) ( <br /> Inspector. Drilling rig type <br /> Permit No. LK I Z – M�lj 1• �br r Auger O.D. I.D. <br /> Completion - Stove pipe/chrisde box (cL�cle one) <br /> Drilling Company: <br /> casing <br /> Driller: height <br /> Consultant— <br /> . \ <br /> Geologist MYE-GRCUNo c4-n2TY-Box <br /> COWLETION ( 4?CcfICN <br /> SPECIAL PERMIT INFO. — nd Suixy T <br /> grat <br /> Distance to sewer line II <br /> Domestic well on site.- (Y1 n) ft <br /> if yes, location and distance - <br /> - o <br /> - = e <br /> SAMPLING SK-ic <br /> socicn — <br /> Holding Temperature <br /> Method "• <br /> Screening Method <br /> Tracking Sheet •.0 y/ n) = n <br /> tt. <br /> SPOILS <br /> MATERIALS/DMLOPMENT <br /> Storage Method <br /> Contamination Noted - (y/ n) Casing type <br /> Storage Location Blank fc. Screen ft. <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Miz Ratios Surge Block: - (y/n ) <br /> 4Itstallation Method Discussed with geologist: - (y/ n) <br /> Quantity Installed Type of ncthod <br /> EH 29 29 <br />