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MONITORING WELL INSTALLATION REPORT <br /> Date: 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 /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: <br /> Completion - Stove pipe/christie box (circle one) <br /> Driller: <br /> casing <br /> Consultant height <br /> Geologist ;V <br /> ABOVE-GROUND <br /> OOMPLETION CHR*-rY-BOX <br /> SPECIAL PERMIT INFO GCOMPLETION <br /> �-�•�� round Surlacs <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - �. n <br /> n, n. <br /> m <br /> SAMPLING = o <br /> slotted = c <br /> Holding Temperature sac9on ' _ a <br /> Method ax = gn m pack <br /> Screening Method <br /> Tracking Sheet - (y/n) _ <br /> :a — <br /> ft. w = <br /> SPOILS ft. <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted- (y/n) <br /> Storage Location Casing type <br /> Blank ft. Screen g, <br /> GROUTING Slot size <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios Bags sand/gravel <br /> Filter Pack type/size <br /> Installation Method Surge Block: - (y/n) <br /> Quantity Installed Discussed with geologist: - (y/n) <br /> EH 29 29 <br /> Type of method <br />