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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 rig type <br /> Perini[No. <br /> Auger O.D. I.D. <br /> Completion - Stove pipe/cluisde box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: � height <br /> Consultant W <br /> Geologist AjCVE-GRCUND V-iRz-rY-T'30X <br /> COWLETION CVAPLEMON <br /> SPECIAL PERMIT INFO. "rte Grcurd Sutx� <br /> Ott <br /> Distance to sewer line <br /> -E <br /> Domestic well on site - (y/ n) .-ft. <br /> If yes, location and distance - tt. <br /> tt. <br /> — C <br /> itoC.Dd � <br /> SAMPLING soden — <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) Casing type <br /> Storage Location Blank fc. Screenft <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> MFilter Pack <br /> Mix Ratios 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 />