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U PAGE_�_OF_� _ <br />MONITORING WELL INSTALLATION REPORT <br />Date: <br />Premise Address: <br />Inspect: <br />Permit No. f� <br />Consultant t/ <br />Geologist <br />SAMPLING <br />Holding Temperature <br />Method <br />Screening Method <br />Tracking Sheet (y/n) <br />SPOILS <br />Storage Method JQ <br />Contamination Noted - yes <br />on <br />Storage Location <br />SPECIAL PERMIT INFO. <br />n <br />Distance to sewer line <br />Domestic well on site - yes <br />If yes, location & distance - <br />GROUTING <br />Depth to water l� ' <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />Total Billed'Time Per Site <br />Date Permit Finalized <br />CONSTRUCTION <br />Well No. <br />Total Depth <br />Screen Length_ <br />Filter Pack <br />Bentonite Pellets <br />Grout ri V0 rPWE <br />Completion -Stove pipe/ck <br />Auger O.D. <br />Auger I.D. <br />_ sty' � <br />_ <br />� boxes <br />A <br />MATERIALS USED: <br />Casing type C " <br />Blank_ ft.. Screen -D ft. <br />Slot size fJ -V I <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />