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M0NIT4RiNG WELL INSTALI-ATION REPORT <br /> CONSTRUCTION <br /> Date <br /> Total, Depth <br /> Premise Address' Screen Length Cfrorn) (to) <br /> Filter Pack (from) (to) <br /> Well No.: $ Bentonite (from) (to) <br /> Grout (ftom) (to) <br /> Inspector Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company, <br /> casing <br /> Driller: height <br /> TFM7 <br /> Consultant <br /> A <br /> Geologist 12OYE-G Clnli7 ck- ;STY-2OX <br /> C3roc;;x�S�si�;.t <br /> SPECIAL PERMIT INFO. <br /> Distance to sewer line �ft. <br /> Domestic well an site - ( y/ n} f+ <br /> if yes, location and distance - �tt <br /> 0 <br /> SAMPLING s*,:�cn <br /> ^- <br /> Holding Temperature f <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ nV. <br /> SPOILS <br /> MATERIALS �i.OPMENT <br /> Storage Method <br /> Contamination Noted - (y/ n } Casing type <br /> Storage Location Blame fr Screen f <br /> Slot size <br /> Bags cement <br /> GR_. OLMNG Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Ratios Surge Block. - ( y/ 11) <br /> -\Installation Method Discussed vAth geologist. - (y/ n } <br /> Quantity Installed Type of method <br /> EH 29 29 <br />