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k <br /> Y <br /> MONITORING WELL INSTALLATION REPORT <br /> a - <br /> Date: ! CONSTRUCTION - <br /> Premise Address: Total Depth <br /> `Screen Length (from) (to) <br /> Well No.: ' Filter Pack (from) (to) <br /> ' n Bentonite (h'om) (to) <br /> Inspector: /�-, <br /> Grout. (from) (to) <br /> Drilling rig type <br /> k Y <br /> Permit No. Auger O.D. I.D.f .. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller': 7- }Le:ght <br /> Consultant - 1 <br /> Geologist AgpVE-GR�yD <br /> coWt.�sQr� Q-iR TY-aox' <br /> cof,PLmoN <br /> SPECIAL PERMIT INFO. Ground SLewe <br /> grCUT <br /> Distance to sewer line <br /> Domestic well on site .- (y/ n) tt. <br /> If yes, location and distance - • <br /> It. <br /> SAMPLING slot" � 1 <br /> soden <br /> Holding Temperature _ — yravV1 P-wX <br /> Method <br /> Screening Method .r <br /> Tracking Shcet (y/n ) <br /> SPOILS <br /> Storage Method MATERIALS EVELOPMENT <br /> Contamination Noted- (y/n) <br /> Storage Location Casing type <br /> Blank ft Screen n• <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 /> Type:of method <br /> EH"2}29 7 <br />