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MONITORING WELL INSTALLATION REPORT <br /> f �r <br /> f <br /> a+ <br /> Dater _ CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: '"� �' Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: _ _ Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. T.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height ' <br /> Consultant �ec�.�-`— _ ._... 7, T'9_ 1. <br /> Ge6mst ._ <br /> ABOVE-GROUND r lsrr-aox <br /> CO W LET;ON COMPLEMON <br /> SPECIAL PERMIT INFO. Ground Surface <br /> graft <br /> Distance to sewer line ' r <br /> Domestic well on site - (y/ n ) � f0 ?S ♦ >t. <br /> If yes, location and distance - <br /> SAMPLING �'I slatted — <br /> Holding Tem erature .v _ <br /> VA <br /> Method UDA '-= pack <br /> Screening Methoh P44 <br /> Tracking Sheet - 10/ n ) <br /> SPOILS <br /> Storage Method MATERIALS12EVELOPMENT <br /> Contamination Noted - {y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> slot size <br /> GRQMNG 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 />