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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) (to) <br /> Inspector. Grout (from)—(to)— <br /> Drilling <br /> from) (to)Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: � casing <br /> height <br /> Consultant <br /> Geologist ABOVE-GRCUND CHRLy-3OX <br /> COMPLETION CCMPt—EMCN <br /> SPECIAL PERMIT INFO.Sudxa + <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) tt. <br /> If yes, location and distance - tt. <br /> — m <br /> = o <br /> SAMPLING doted <br /> sacicn — <br /> Holding Temperature = pavd F <br /> Method = <br /> Screening Method__ <br /> Tracking Shcet - (y/ n ) <br /> ILLtt. <br /> r03I.f <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft Screen ft• <br /> Slot sizeQ ^/D <br /> GROUTING Bags cement — <br /> n Buckets bentonite <br /> Depth to water /�J.�' Z� �Eis Bags sand/gravel <br /> Mix Ratios. Filter Pack type/size L <br /> Installation Method Surge Block: - ( y/ r)' <br /> Quantity Installed Discussed with geo ogist•. - / n ) <br /> Type of method <br /> EH 29 29 <br />