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MONITORING WELL INSTALLATION REPORT <br /> Date• <br /> n/���/� � 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 /> casing <br /> Driller: _ height <br /> Consultant <br /> 7, <br /> Geologist AggyEGFICUND <br /> CMP L.E710 N Ct�RSTY-BOX <br /> A <br /> COMPL=-nCN <br /> SPECIAL PERMIT INFO. Ground SLzf <br /> flrart <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - ft. <br /> ft. <br /> M <br /> SAMPLING slorai = <br /> socicn = <br /> r - <br /> Holding Temperature <br /> Method = _ <br /> Screening Method <br /> Tracking Sheet - (y/ n) '— <br /> n. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type ' <br /> gl 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 Block: - (y/ n ) <br /> Quantity Installed Discussed vrith geologist: - (y/n) <br /> Type of method <br /> EH 2(,M <br />