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F <br /> MONITORING WELL INSTALLATION REPORT <br /> � .� <br /> CONSTRUCTION <br /> Date: !' <br /> l Depth <br /> fib �� ( <br /> Premise Address: Totaep <br /> Screen Length (from) to) <br /> � �� Filter Pack (from) (to) <br /> � <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 /> casing <br /> Driller: � I height <br /> 'V <br /> Consultant - \ <br /> Geologist— ABOVE-GRCUND C`G�-Box <br /> CowLETfON CCMPL TCN <br /> r.o C+rwrd Su(act <br /> SPECIAL PERMIT INFO. "CLI <br /> Distance to sewer line — (t, <br /> Domestic well on site - ( y / n ) ft. <br /> If yes, location and distance <br /> = c <br /> �p - <br /> SAMPLING sucicn __ <br /> _ � = ttavnt Faac <br /> c <br /> Holding Temperature <br /> Method — <br /> ing Method _ <br /> Screen , <br /> Tracking Sheet - ( y / n ) <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method <br /> Contamination Noted • ( y / rt ) Casing type K, <br /> Storage Location Blank ft. Screen <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Block: - ( y / n ) <br /> Mix Ratios Surge <br /> dttstalladon Method Discussed With geologist: - ( y / n ) <br /> Quantity Installed Type of method <br /> EH 29 29 <br /> I - <br />