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MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> �X71 CONSTRUCTION <br /> Premise (Address: �� &V-`1 L4'aqTotal Depth <br /> �— Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: _ Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist/ 6 1 <br /> ABOVE-GACUND CHRISTY-BOX <br /> COMPLETION COMPLEMN <br /> SPECIAL PERMIT INFO. ®o Ground Suc1"y <br /> Distance to sewer line otaa <br /> Domestic well on site - ( y/ n ) ft. <br /> If yes, location and distance - {t, <br /> R. <br /> �i <br /> — a <br /> SAMPLINGtlorai <br /> soc*cn <br /> Holding Temperature = �vd pads <br /> Method = <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> ft. <br /> = ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVEI.OPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ it ) <br /> Quantity Installed Discussed with geologist - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />