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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/cluistie box (circle one) <br /> Drilling Company: — <br /> Driller: casing <br /> —:F height <br /> Consultant — <br /> Geologist — ABCyE-GRAD <br /> CCMPL_�TfON CKR:STY-30X <br /> CCt„lQt..ET1CN <br /> SPECIAL PERMIT INFO. Grourd Sulact <br /> greet <br /> Distance to sewer line <br /> Domestic well on site - ( y/ n) ft. <br /> If yes, location and distance - ft- <br /> ft. <br /> O <br /> SAMPLING tloro.i = <br /> socicn <br /> Holding Temperature :; = 4RYvt pack <br /> Method -}� — <br /> Screening Method _ . <br /> Tracking Sheet - (y/ n ) -= <br /> SPOILS 1 <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen fr• <br /> Slot size C,C L' <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 mediod <br /> EH 29 29 <br />