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MONITORING WELL INSTALLATION REPORT <br /> Date: % a CONSTRUCTION <br /> Premise Address: / V___ 4-c— � � Total Depth <br /> Screen Length (from) (to) <br /> Well No.: A�� �"I Z Filter Pack (from) (to)- <br /> J' Bentonite (from) (to) <br /> Inspector: 9tZ f' „ . 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 T <br /> Geologist T <br /> ABOVE-GROUND 0-IMM-Box <br /> SPECIAL PERMIT INFO. Ground Surface COMPLETION <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n ) <br /> If yes, location and distance - n• <br /> F <br /> SAMPLING <br /> slottad <br /> socaon g <br /> s: . <br /> Holding Temperature <br /> gmA Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet (y/n) <br /> JL <br /> SPOILS <br /> Storage Method MATERIp►LS EVELOpMENT <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 /> EH 29 29 Type of method <br />