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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 /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: —_ 'Y(�, casing <br /> l 4 <br /> Consultant +� height <br /> Geologist _—_ T <br /> ABOVE-GROUND <br /> C C MP LET{O N CNA 15TY-8C)X <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line groLt <br /> Domestic well on site - (y/n ) <br /> If yes, location and distance - <br /> --- ft. <br /> = m <br /> C <br /> SAMPLING = o <br /> abtted .: � <br /> on <br /> Holding Temperature _ <br /> Method _ — gMV94 Pack <br /> Screening Method _ <br /> Tracking Sheet ( y/ n ) <br /> ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location _ _ Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water 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 /> Type of method <br /> EH 29 29 <br />