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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 /> Driller: casing <br /> F -t'WT <br /> 1 � height <br /> Consultant IV <br /> ITA <br /> Geologist Im <br /> ABOVE-GRCUND C4-RRZ7Y-30X <br /> COF.SRt��TfON C MPUTCN <br /> SPECIAL PERMIT INFO. Grct-md Sutxs '— <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) ft, <br /> If yes, location and distance - <br /> ft. <br /> ft. <br /> C <br /> SAMPLING 2 <br /> tQcicn — <br /> B <br /> Holding Temperature '' <br /> Method r <br /> Screening Method } <br /> Tracking Shcec (y/ n ) — <br /> ft. <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 />