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MONITORING WELL INSTALLATION REPORT <br /> CONSTRUCTION <br /> Date: ` • � <br /> Total Depth <br /> Premise Address: Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Well No.: Bentonite (from) <br /> Grout (from) (to) <br /> Inspector. Drilling rig typ <br /> Auger O.D. ` I.D. <br /> Permit No. Completion - Stove pipe/cluistie box (cL-cle one) <br /> Drilling Company: <br /> casing <br /> Driller': height V '� \ <br /> Consultant <br /> 71- <br /> Geologist A°AVE-GRCUND <br /> CGIVPL TSCN GOf,+r't_i1CN <br /> . Cxoc:rd SuixY <br /> SPECIAL PERMIT INFO. <br /> Distance to sewer line <br /> Domestic well on site .- (y/ n) I� <br /> if yes, location and distance - f!. <br /> ~ O <br /> � M <br /> • 3IO C'.� ._ c <br /> SAMPLING socicn - <br /> r <br /> Holding Temperature— <br /> Method = <br /> Screening Method _ <br /> Tracking Shcet - (y/'n) — <br /> �. ft. <br /> ft. — <br /> -.---. <br /> SPOILS <br /> MATERI ALS/DEVEI.OPMENT <br /> Storage Method 5w <br /> Contamination Noted - (y/ n) Casing type �w �°�` <br /> Storage Location Blank ft- Screen--------- <br /> slot <br /> creen —Slot size U 0" <br /> Bags cement —� <br /> GROUTING Buckets bentonite ------ <br /> Bags sand/gravel <br /> Depth to water Fdtcr Pack�type/size 3 —� <br /> Mix Ratios Surgc Block: - (y <br /> pstallation Method Discussed with geologist: - n) <br /> Quantity Installed_ Type of metliod <br /> EH 29 29. . <br />