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'v ONITORING WELL INSTAUATION REPO <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/clu-istie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant 5 '4 <br /> Geologist <br /> ABOVE-GRCUIVD CHRMTY43OX <br /> coWPLETIont comkincN <br /> SPECIAL PERMIT INFO Ground Surface ��-�•—.••.••� <br /> Distance to sewer line Qrait <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - <br /> ....,-....ft. ft. <br /> 'Nr - <br /> Y r O <br /> r4r � <br /> SAMPLING ilor.�.9 <br /> sacacn <br /> Holding Temperature Y' <br /> Method <br /> Screening Method _ <br /> Tracking Sheet - (y/n ) <br /> �.r.....ft. __.... "Y = ft. <br /> SPOILS <br /> Storage Method MATERIALS EVELOPMENT <br /> Contamination Noted - (y/n ) <br /> Storage Location Casing type <br /> Blank ft. Screen h. <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 BIock: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br />