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MONITORING WELL INSTALLATION REPORT <br /> CONSTRUCTION <br /> IbJ� <br /> Date: ,�/ <br /> Total Depth <br /> Premise Address: Screen Length (from) <br /> Filter Pack (from) (to) <br /> Well No.: Bentonite (from) (to) <br /> Grout (from) (to) <br /> Inspector. Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller• y height <br /> 1 V <br /> Consultant d- <br /> Geologist ABOVE-GROUND CHRZ'IY-Box <br /> COMPLETION CIVAPL.LTICN <br /> Ground Sutacs <br /> SPECIAL PERMIT INFO. ' <br /> prurt <br /> Distance to sewer line _ <br /> Domestic well on site - (y/n) ft. <br /> If yes, location and distance - <br /> SAMPLING sQcicn = <br /> Vr1Y91Pack <br /> Holding Temperature <br /> Method <br /> Screenin;Method <br /> Tracking Shcet - (y/ n) .._ <br /> SPOILS <br /> MAT ERIALS/DEVELOPMENT <br /> Storage Method <br /> Contamination Noted - (y/n) Casing type <br /> Storage Location Blank ft. Screen_________ ft. <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Rados Surge Block: - (y/ n) <br /> Installation Method Discussed with geologist: - (y/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />