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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 /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> Driller: 'Y casing <br /> 4 <br /> Consultant height <br /> Geologist <br /> ASCVE-GROUND <br /> 00WLETI0N CJ-sz Y-30X <br /> SPECIAL PERMIT INFO. COMPLETICN <br /> Ground Surlaca <br /> Distance to sewer line gr= <br /> Domestic well on site - (y/n ) 1 <br /> If yes, location and distance - _T n <br /> _ a <br /> SAMPLING __ o <br /> slotted w: c <br /> Holding Temperature — <br /> Method 9m„1W pack <br /> Screening Method <br /> Tracking Sheet - (y/n ) _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) <br /> Storage Location Casing type <br /> Blank ft. Screen fr, <br /> GROUTING Slot size <br /> Bags cement <br /> Buckets bentonite <br /> Depth twater _ 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 <br /> Type of method <br />