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MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> CONSTRUCTION <br /> Premise Address: Total Depth <br /> Well No.: Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Inspector: Bentonite' (from) (to) <br /> Grout (from) (to) <br /> Permit No. Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Company; Completion- Stove pipe/christie box (circle one, <br /> Driller: <br /> casing <br /> Consultant height <br /> r , <br /> Geologist <br /> ABOVE-GROUND <br /> COIJPLETION CNA1M4M <br /> SPECIAL PERMIT INFO. COMPLETiON <br /> Ground Surfxe <br /> Distance to sewer line– grout <br /> I Domestic well on site - (y/n) <br /> If yes, location and distance- tt <br /> tt. <br /> SAMPLING = — c <br /> alottad `7 — c <br /> Holding Temperature "r'0^ i —_ <br /> Method <br /> Screening Method r = •• <br /> Tracking Sheet - (y/n) <br /> SPOILS <br /> Storage Method MATFRIALS/DEVELOPMENT <br /> Contamination Noted- (y/n) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> GROUPING Slot size <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios Bags sand/gravel <br /> Installation Method Filter Pack typesize <br /> -- — ----–$urge Block:—(.y_/–n_) <br /> Quantity Installed Discussed with geologist: - (y/n) <br /> EH 29 29 Type of method <br />