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r ry <br /> MONITORING WELL INSTALLATION REPORT <br /> Date• - CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> } <br /> Well No.-' Filter Pack (from) --CEO) <br /> � ' ' <br /> 1 Bentonite (from) (to) <br /> Inspector. ' Grout (froth) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. LD. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing ` <br /> Driller: he;ght: <br /> FM <br /> Consultant <br /> Geologist ABOVE-GRAD C_0AZ Y-30X <br /> 0ONFLEMN cor, tnmcr� <br /> SPECIAL PERMIT INFO. Grourd Sutact <br /> grcut <br /> Distance to sewer line R # <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - tt- <br /> ft. <br /> O <br /> SAMPLING — <br /> sacycn <br /> .V <br /> Holding Temperature 01 Pack <br /> Method t — <br /> Screenino Method —_ <br /> Tracking Sheet (y/ n) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <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 /> Type of method <br /> EH 29 29 t <br /> i <br />