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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 Park (from) rr�l <br /> l� J <br /> Bentonite (from) (to) <br /> Inspector: 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: <br /> �(—, casing <br /> I height <br /> Consultant t <br /> —fig <br /> Geologist .� ��T <br /> ABOVE-GROUND <br /> CO,FLETION Cin1STY-60X <br /> SPECIAL PERMIT INFO. Ground Surface _ <br /> COMPLETION <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - ft• <br /> ft. <br /> -- q <br /> C <br /> SAMPLING slatted = <br /> — m <br /> Holding Temperature <br /> Method = v"`�pack <br /> Screening Method — <br /> Tracking Sheet ( y/n ) <br /> tt. ==4 I Fft. <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 />