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MONITORING WELL INSTALLATION REPORT <br /> CON�UCTI ON <br /> Date: � <br /> >/ o [ <br /> Premise Address:— Total Depth Screen Length (from) (to) <br /> M l._ 1Q 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/cli istie box (circle one) <br /> Drilling Companre.C4 co <br /> � casing <br /> Driller: � height <br /> Consultant S <br /> Geologist ABpV&GRCUND CtW15TY30X <br /> ccwLET*N cCWLEnON <br /> Ground suiacf <br /> SPECIAL PERMIT INFO. <br /> grcut <br /> Distance to sewer line } It. <br /> Domestic well on site - ( y / n ) ft <br /> If yes, location and distance - <br /> donAi <br /> SAMPLING soden <br /> M = P1Y9I1� <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - C Y / n <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method <br /> Contamination Noted - ( y / n ) Casing type <br /> Storage Location Blank ft. Screen —fr <br /> Slot size <br /> Bags cement_ <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Ratios Surge Block: - ( Y / tl ) <br /> Installation Method Discussed with geologist: - ( y / n ) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />