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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/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: / l height <br /> Consultant <br /> GeologistC ii ''`�'`- AE E-GRAD <br /> CONFLETION C-C+ .STY-30X <br /> COt.4PL.ET1CN <br /> SPECIAL PERMIT INFO. Ground Suiaxt <br /> pram <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - ft- <br /> �� <br /> vy � <br /> - C <br /> O <br /> SAMPLING sloro.i = <br /> soden <br /> Holding Temperature <br /> Method =* _ <br /> Screenin;Method = <br /> Tracking Sheet - (y/n) ^` <br /> IT13 — <br /> � ':. ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVEI,OPMENT <br /> Contamination Noted - (y/ n) ') " t''-'„ <br /> e <br /> Storage Location Casing tYP <br /> Bl� 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/11) <br /> Quantity Installed Discussed Vrith geologist. - (y/ n) — <br /> Type of method <br /> EH 29 29 <br />