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MONITORING WELL INSTALLATION REPORT <br /> - r - <br /> CONSTRUCTION <br /> Date: <br /> Total Depth <br /> Premise Address: Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Well No.- Bentonite (from) (to) <br /> Grout (from) (to) <br /> inspector. Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: _ height <br /> - V <br /> Consultant <br /> Geologist /.'AVEE-GFICUND <br /> CUYPLETfON cOMPLFncN <br /> - - Grxmd Sutaet <br /> SPECIAL PERMIT INFO. <br /> yrad <br /> Distance to -ewer line • <br /> Domestic well on site - (y/ n ) f2 <br /> If yes, location and distance - <br /> - = c <br /> —• o <br /> SAMPLING sbrad <br /> secicn —_ <br /> Holding Temperature <br /> Method ='• <br /> Screening Method = <br /> Tracking Sheet - (y/ n) 'r — <br /> ft <br /> SPOILS <br /> MATERS ALS/DEWt,OPMENT <br /> Storage Method <br /> Contamination Noted - (y/ n) Casing type <br /> Storage LocationBlank fr. Screen f . <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets ben[oni[e <br /> Bags sand/gravcl <br /> Depth to water Filter Pack type/size <br /> Mix Rados Surge Block: - (y/11) <br /> -Jpstalladon Method Discussed with geologist: - (y <br /> Quantity lnstalied Type oEmcd[od <br /> EH 29 29 <br />