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MONITORING WELL INSTALLATION REPORT <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/cluistie box (circle one) <br /> Drilling Company: <br /> T_ casing <br /> Driller: �� height <br /> V � } <br /> Consultant <br /> Geologist APOYrGRCUND CkF' -BOX <br /> cc)WLETfCN r ?tnncN <br /> Ci=rzi Suix+ --t—-- <br /> SPECIAL PERMIT INFO. T <br /> prat <br /> Distance to sewer line __ _ft <br /> Domestic well on site .- (y/ n) tt <br /> If yes, location and distance - <br /> = a <br /> slarad = � <br /> SAMPLING soc cn <br /> Holding Temperature = F <br /> Method <br /> Screening Method j <br /> Tracking Shcet - (Y/n) = tt <br /> R. <br /> SPOILS <br /> M ATE RI ALS/D E V E LOP MENI' <br /> Storage Method <br /> Contamination Noted - (y/ n) Casing type <br /> Storage Location ft Screen__—n' <br /> Blank <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Rados Surge Block: - (y/n) <br /> dlts[allation Method Discussed vAth geologist: - (y/ n) <br /> Quantity Installed Type of mcdtod —� <br /> EH 29 29 <br />