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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: 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 <br /> from) (to)Permit No. Ding rig type ' <br /> Auger O.D. I.D. <br /> Drilling Company: Completion - Stove pipe/chn'stie box (circle one. <br /> Driller: <br /> casing <br /> Consultant <br /> height <br /> Geologist <br /> I <br /> ABOVE-6FIOUND <br /> COMPLETION cHRz 1-Box <br /> SPECIAL PERMIT INFO. COMPLEiiON <br /> G=rd SUrfaoe <br /> Distance to sewer line Grout <br /> Domestic -well on site (y/n) <br /> If yes, location and distance- 1 ft <br /> Y� 0 <br /> SAMPLING <br /> elo ttad - — c <br /> Holding Temperature <br /> Method <br /> Screening Method A4 <br /> Tracking Sheet - (y/n) <br /> ft• K ,• I{- <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted • (y/n) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> GROUTING Slot size <br /> Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method _,_ SurgeBlock:=(_y--/na_ <br /> QuaritityInstalled Discussed with geologist: - (y/n ) <br /> EH 29 29 Type of method <br />