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MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> CONSTRUCTION <br /> Premise Address: <br /> Total Depth <br /> Well No.: Screen Length (from) (to) <br /> Filtet 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/chnlstie box (circle one <br /> Driller: <br /> casing <br /> Consultant height <br /> Geologist <br /> ABOVE-GROUND <br /> CONFLETION CHAISTKBcx <br /> SPECIAL PERMIT INFO. COMPLETION <br /> Ground Surface <br /> Distance to sewer line <br /> Domestic well on site - (y/n) <br /> grout <br /> If yes, location and distance- tt <br /> s <br /> 9S P <br /> SAMPLING . = e <br /> clotted — c <br /> Holding Temperature <br /> Meth <br /> Scree I _ '• g"vet Past . <br /> Screening Method _ ..' <br /> Tracking Sheet - (y/n) <br /> tt. = <br /> SPOILS tt- <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted- (y/n) <br /> Storage Location <br /> Casing type <br /> Blank $. Screen ft. <br /> GROUTING Slot size <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios Bags sand/gravel <br /> Installation Method Filter Pack type/size <br /> Quantity Insfalled — <br /> Discussed with geologist: - (y/n) <br /> EH 29 29 Type of method <br />