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MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> CONSTRUCTION <br /> Premise Address: Total Depth <br /> Well No.: Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Inspector: Bentonite (from) (to) <br /> Grout (from) (to) <br /> Permit No. <br /> Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Company: Completion - Stove pipe/chnstie box (circle one) <br /> Driller: <br /> casing <br /> Consultant <br /> height <br /> Geologist .' <br /> JdriO VE-G A OUND <br /> a I,r'LETfON C_HRZ Y-8CX <br /> SPECIAL PERMIT INFO COMPLE7CN <br /> Grind Suiac9 <br /> Distance to sewer line o+ <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance <br /> O <br /> m <br /> SAMPLING — <br /> . <br /> Holding Temperature <br /> Method = ;r'Y'4 Pack <br /> Screening Method = <br /> Tracking Sheet - (y/n ) _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) <br /> Storage Location <br /> Casing type <br /> Blank ft. Screen ft <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 /> Surge Block:__(Y/n-)--- _ <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> EH 29 29 Type of method <br />