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MONITORING WELL INSTALLATION R" )RT <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/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> ConsultantWV <br /> Geologist •� <br /> ABOVE-GROUND <br /> COWLErZN COMPLE70N <br /> COMPL.�T1CN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line _ Droul <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - <br /> ft. <br /> = r <br /> _ o <br /> SAMPLING •torted = <br /> aecaon <br /> Holding Temperature I _ 71„w Pack <br /> Method — <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 ft. <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/ n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />