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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 <br /> (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: Completion - Stove pipe/cliristie box�(circle one) <br /> Driller: casing <br /> I <br /> � heightConsultantGeologist �. <br /> ABCVE-GACOND <br /> COWL_`TON C %'R*TY3pX <br /> SPECIAL PERMIT INFO CCMPLEnCN <br /> Cirwnd Suiaca <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance <br /> • ft. <br /> ft. <br /> SAMPLING o <br /> Monad — c <br /> sacicn — <br /> Holding Temperature <br /> Method _ = gmy9f Pack <br /> Screening Method = <br /> Tracking Shcet - ( y/ n) "< — <br /> :., <br /> ft. — --ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) <br /> Storage Location Casing type�7 jrfp <br /> VG <br /> Blank fL Screen g, <br /> GROUTING Slot size 0• 2 P1 <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> EH 29 29 Type of nethod <br />