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MONITORING WELL INSTALLATION REPORT <br /> Date:- CONSTRU__CTION <br /> Premise Address: 4 c;�' Total Depth <br /> 17 Screen Length (from) (to) <br /> Well No.: �'�` --� Filter Pack (from) (to) <br /> Bentonite (from) (to) /3 <br /> Inspector: Grout (from) - (to) 9,_'5Drilling rig type t.t� ��m <br /> Permit No. Auger O.D. ? " I- <br /> Completion - Stove pipe/ r"_ de box circle one) <br /> Drilling Company: 121 <br /> t D casing <br /> Driller: <br /> height <br /> Consultant � � �L---� 711, � <br /> Geologist %�^"'"` 1180VE-GRCCIND <br /> COt�Pl-.`T40N CHMM-Box <br /> COMPL=_MCN <br /> SPECIAL PERMIT INFO. Ground Sufxs <br /> prCut <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) ft, <br /> If yes, location and distance - ft. <br /> ft. <br /> SAMPLING <br /> sa-�cn <br /> Holding Temperature =_ 71 94 Facx <br /> Method = <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> _._-..ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type --- <br /> Blank l.` ft. Screen I O R• <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 />