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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 /> height <br /> Consultant 1.71T- <br /> Geologist <br /> /180VE-GACUNO _WV <br /> CONFLEMN CHRIM_aox <br /> SPECIAL PERMIT INFO. Ground Surfact COMPLETION <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft <br /> v o <br /> — r <br /> SAMPLING ' — o <br /> sockn 1• —' <br /> Holding Temperature <br /> Method ;;; _ gmva pack <br /> Screening Method - <br /> Tracking Sheet - ( y/ n ) <br /> ft. Liu 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/ ii ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> EH 29 29 Type of method <br />