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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Total Depth <br /> Premise Address: <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. Grout (froth) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: � height <br /> Consultant <br /> -WVT <br /> Geologis <br /> CONFLET ON Ct4at571 Ot� nCN <br /> C1PL°TICN <br /> Grouixf <br /> SPECIAL PERMIT INFO. nd Sacs <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) It <br /> If yes, location and distance - tt• <br /> tt. <br /> - = o <br /> c <br /> a <br /> liOnY� <br /> SAMPLING sacicn = S <br /> Holding Temperature _ vlyf l Pack <br /> Method == _ <br /> Screening Method <br /> Tracking Sheet - (y/ n) <br /> tt — 12. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) Casing type <br /> Storage Location Blank fc. Screen —ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to waterBags sand/gravel <br /> Filter Pack type/size <br /> Mix Ratios <br /> uSurge Block: - ( e/nstallation Method ) <br /> Discussed with geologist: - (y/ n <br /> Quantity Installed ) <br /> Type of method <br /> EH 29 29 <br />