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MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from)' (to) <br /> Well No.: Filtet Pack (from) (t) <br /> Inspector: Bentonite' (from) (to) <br /> 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. c as ing <br /> Consultant <br /> height <br /> Geologist ff <br /> -i <br /> ABOVE-GROUND T <br /> COMPLETION CFffl15T7$OX <br /> SPECIAL PERMIT INFO COMPLETION <br /> Cirnund Swiace <br /> Distance to sewer line orart <br /> Domestic well on site - (y/n) <br /> If yes, location and distance- h <br /> • ft ft. <br /> SAMPLING = c <br /> slo Mad <br /> Holding Temperature <br /> Method = pr,y9,p <br /> Screening Method <br /> Tracking Sheet - (y/n) . <br /> SPOILS <br /> 4 <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted- (y/n) <br /> Storage Location Casing type <br /> Blank ft. Screen g, <br /> GROUTING Slot size <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios Bags sand/gravel <br /> Installation Method Filter Pack type/size <br /> -- <br /> Quantity -- � ----..Surge-Block: <br /> Installed — <br /> Discussed with geologist: - (y/n) <br /> EH 29 29 Type of method <br />