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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. LI]• <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> he, <br /> Consultant ` <br /> Geologist <br /> ABOVE-GRMND CHRMTY-BOX <br /> COWFLETION CCUPLEMON <br /> SPECIAL PERMIT INFO. Ground Surf=* <br /> Distance to sewer line orurt <br /> Domestic well on site - (y/ n) _y t!. <br /> If yes, location and distance - - <br /> d� M <br /> C <br /> o <br /> SAMPLING iiorai <br /> r, c cn - <br /> Holding Temperature <br /> Method — v� <br /> Screening Method tv — <br /> Wracking Shcet - (y/ n ) 71 _ <br /> SPOILS <br /> Storage Method MATERIALS/DEWI.OPMENT <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 ivater 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 />