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MONITORING WELL INSTALLATION REPORT <br /> Date: o ( Z CONSTRUCTION <br /> Premise Address : aG 0 (� Total Depth <br /> Screen Length (from) (to) <br /> Well No. : Filter Pack (from) (to) <br /> (� Bentonite (from) (to) <br /> Inspector. lJ c\� A- O- 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 /> he _ght <br /> Consultant <br /> Geologist M <br /> ABOV&GRCUND ct4i�STY$OX <br /> COMPLETION ccmn. ncN <br /> Grou <br /> SPECIAL PERMIT INFO. �'�' nd S�rfx� + <br /> prcut <br /> Distance to sewer line <br /> Domestic well on site - ( y / n ) ft. <br /> if yes, location and distance <br /> K. <br /> c <br /> SAMPLING tlotoi <br /> tocicn —_ <br /> Holding Temperature <br /> Method _ <br /> Screening Method = <br /> Tracking Sheet - ( y / n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y / n ) <br /> Storage Location Casing type ft <br /> Blank fc Screen <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 / n ) <br /> Quantity Installed Discussed with geologist: - ( y / n ) <br /> Type of method <br /> EH 29 29 <br />