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f' <br /> MONITORING WELL INSTALLATION REPORT <br /> CONSTRUCTION <br /> Date: <br /> Premise Address: `' Total Depth <br /> Screen Length (from) ( o) <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 /> Consultan —QNt <br /> Geologist ABOVE-GRCUND C�-nZ7Y-BCX <br /> caWLETfON CO&tPLETICN <br /> „mo o Grw <br /> SPECIAL PERMIT Iiv' rid S"lact 0FO. <br /> prat <br /> Distance to server line <br /> Domestic well on site - (y/ n) It. <br /> If yes, location and distance - h' <br /> tt. <br /> - -- C <br /> O <br /> SAMPLING <br /> Holding Temperature <br /> Method_ <br /> Screening Method = <br /> Tracking Sheet - (y/ n) _ <br /> SPOILS <br /> Storage Method MP.TERIALS/DEVELOPMENT <br /> Contamination Noted- (y/ n) Casing type <br /> Storage Location Blank fc Screen --R' <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water_ Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/ n ) <br /> Installation Method Discussed with geologist: - (y/ n) <br /> Quantity installed Type of method --� <br /> EH 29 29 <br /> 1 - <br />