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MONITORING WELL INSTALLATION REPORT <br /> Date:. �'D CONSTRUCTION <br /> Premise Address: <br /> Total Depth S0 <br /> 7S <br /> ` qqScreen Length (from) (to)_ <br /> Well No.: ,f)I W m�V� t,l 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: casing <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE-GROUND <br /> CONFLETION CHRLSTY43OX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> ON <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - <br /> SAMPLING <br /> slotted <br /> saaron <br /> Holding Temperature <br /> Method _— g'�W Pack <br /> Screening Method <br /> n.Tracking Sheet - (y/n ) <br /> P. <br /> SPOILS qs �v <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) �, � <br /> Storage Location Casing type 2 <br /> Blank ft. Screen ft. <br /> Slot size 0.02-0 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water ® Bags sand/gravel <br /> Mix Ratios L&ACen.._ 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 />