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1 casing <br />vt, height <br />CI-EA:STY-BOX • <br />COMPt-71CN <br />11 <br />ABOVE-GRCUND <br />CC fv9 LETO N <br />MONITORING WELL INSTALLATION REPORT <br />Date: /6)/i /6 <br />Premise Address: <br />Well No.: <br />Inspector. /-J twrL- <br />Permit No. <br />Drilling Company: 4/14-117 <br />Driller: <br />Consultant A <br />Geologist <br />CONSTRUCTION <br />Total Depth <br />Screen Length (from) (to) <br />Filter Pack (from) (to) <br />Bentonite (from) (to) <br />Grout (from) (to) <br />Drilling rig type <br />Auger O.D. I .D . <br />Completion - Stove pipe/christie box (circle one) <br />SPECIAL PERMIT INFO. <br /> <br />Distance to sewer line <br />Domestic well on site - ( y / n) <br />If yes, location and distance - <br /> <br />SAMPLING <br /> <br />Holding Temperature <br />Method <br />Screening Method <br />Tracking Sheet - ( y / n ) <br />SPOILS <br />Storage Method <br />Contamination Noted. ( y / n) <br />Storage Location <br />MATERIALS/DEVELOPMENT <br />Casing type <br />Blank ft. Screen ft. <br />GROUTING <br />Depth to water <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />Slot size <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />Surge Block: - ( y / n ) <br />Discussed with geologist: - ( y / n ) <br />Type of method <br />El-I 29 29