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MONITORING WELL INSTALLATION REPMT <br /> Date: 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. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: _,,... casLng <br /> height <br /> Consultant <br /> Geologist <br /> AZCVE-GtgC(JND <br /> COP�L.,c'TlOtd G�ti.STY-s3QX <br /> COMPL MN <br /> SPECIAL PERMIT INFO. C3rvcsrd Sirfacs <br /> Distance to sewer line <br /> Q�«n <br /> Domestic well on site - ( y/ n ) ft. <br /> U yes, location and distance - ft. <br /> tt. <br /> _ m <br /> G <br /> SAMPLING <br /> siorni w� � <br /> sacicn <br /> Holding Temperature 9"v91 W <br /> ck <br /> Method <br /> Screening Method .r. <br /> Tracking Shcet - ( y/ n ) <br /> •F <br /> �• , tt0 <br /> SPOILS <br /> Storage Method MATEWALS/DEtr'ELOPMENT <br /> Contamination Noted - (y/ n } <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> SIot size <br /> GROU'VNG Bags cetnent <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ 11 ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />