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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.- Filter Pack (from) (to) <br /> Bentonite (from)-(co)— <br /> Inspector- <br /> from) (to)InspectorGrout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cluisde box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> IFm height <br /> Consultant , ` <br /> Geologist JOVE-GROUND <br /> COYFL`ET*N COMP EMN <br /> GOt�4'L_"iICN <br /> SPECIAL PERMIT INFO. mrd S + —` <br /> Distance to sewer line arca <br /> Domestic well on site - (y f n ) (t. <br /> If yes, location and distance - ft- <br /> ft. <br /> — o <br /> SAMPLING �lonod <br /> soden - — <br /> Holding Temperature = pavd FaCk <br /> Method <br /> Screening Method <br /> Tracking Shcet - (y/ n ) '? _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen — <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravcl <br /> Mi%Rados Filter Pack type/size <br /> ,installation Method Surge Block: - (y/n) <br /> Quantity installed Discussed with geologist. - (y/ n ) <br /> Type of method — <br /> EH 29 29 <br />