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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/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: � casing <br /> -_ height <br /> Consultant V <br /> Geologist <br /> ABOVE-GACQND CKRZTY3oX <br /> CO MPLEf fON CC*APL^"T1cN <br /> SPECIAL PERMIT INFO. Grouri S�act <br /> Distance to sewer line gran <br /> Domestic well on site - ( y/ n ) ft. <br /> If yes, location and distance - ft. <br /> n. <br /> - = a <br /> — o <br /> SAMPLING ilorcd <br /> X x cn — <br /> Holding Temperature pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> n. = n. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen h• <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/ tt ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />