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MONITORING WELL INSTALLATION REPOitT <br /> Date: ;/7 /LI o CONSTRUCTION <br /> Premise Address : 04 1n . na Total Depth <br /> Screen Length (from) (to) <br /> Well No. : Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: i t9-� Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant G <br /> Geologist <br /> ABOVE"GRMND Ct6tISTY80X ' <br /> COMPLETK)N COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line <br /> proof <br /> Domestic well on site - ( y / n ) L_. ft, <br /> If yes, location and distance - <br /> � ft. <br /> = e <br /> SAMPLING olorud = <br /> /IIp aocion <br /> Holding Temperature C/ = gavotG <br /> Method = <br /> Screening Method = <br /> Tracking Sheet - ( y / n ) _ <br /> fL <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y / n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <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 />