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MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> CONSTRUCTION <br /> Premise Address: Total Depth <br /> Well No.: Screen Length (from)* (to)__ <br /> Filter Pack (from) (to) <br /> Inspector: Bentonite (from) (to)__ <br /> Grout (from) <br /> Permit No. <br /> Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Company: Completion- Stove pipe/chnstie box (circle one) <br /> Driller: <br /> casing <br /> Consultant <br /> height <br /> _QVI <br /> Geologist .w IT <br /> A CVE-GROUND <br /> CoNPLEmN C8RZ_rY-a0X <br /> SPECIAL PERMIT INFO COMPLE MN <br /> Ground Surtaca <br /> Distance to sewer line o+ <br /> Domestic well on site - (y/n) <br /> rocA <br /> If yes, location and distance - ,4 __ft. <br /> SAMPLING = o <br /> 110 Clad c <br /> &*caon <br /> Holding Temperature <br /> — <br /> Method "vs?pack <br /> Screening Method <br /> Tracking Sheet - (y/n) _ <br /> • <br /> SPOILS ft. <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> GROUTING Slot size <br /> Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method_ Block'_=(_y_/n_)_ _ <br /> Quantity Installed Discussed with geologist: - (y/n ) <br /> EH 29 29 Type of method <br />