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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 <br /> from) (to)Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: af <br /> casing <br /> height <br /> Consultant T <br /> Geologist - T <br /> ABOVE-GROUND Cl m-m-80X <br /> COWLETION COMFLEnON <br /> SPECIAL PERMIT INFO. Ground Surlaca <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - ft' <br /> ft. 7 F- <br /> SAMPLTNG �btted j m <br /> Holding Temperature <br /> gntyv�Pack <br /> Method w`f. <br /> —L <br /> "Screening Method ;Tracking Sheet - (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 />