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MONITORING WELL INSTALLATION REPORT <br /> Date:�7� CONSTRUCTION <br /> Premise Address: Total Depth <br /> �[nNi /Je ��7) Screen Length (from) <br /> Well No.: (to) <br /> Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector, bd Grout (from) (co) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/eltrkde box (circle one) <br /> Drilling Company <br /> Driller: casing <br /> Consultant I n height \ <br /> Geologist�(/�/S' \ T <br /> • ABOVE-GROUND <br /> L COMPLEMN CIRLSTY30X <br /> SPECIAL PERMIT INFO. q=r4 Suy CC4APL.EIlCNj�c <br /> Distance to sewer line ora t <br /> Domestic well on site.- (y/n) It <br /> If yes, location and distance - tt <br /> h. <br /> t Y. <br /> M <br /> O <br /> X <br /> SAMPLING <br /> doral �i = c <br /> LOCicn <: _ •� <br /> Holding Temperature — <br /> Method - <br /> iii <br /> Screening Method Y = <br /> Tracking Sheet - (y/ n ) ;- = <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location Casing type�t I� <br /> Blank "V Screen h• <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water_ �-/U. Bags sand/gravel <br /> Miz Ratios R 2y L 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 />