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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> U,�_ Total Depth <br /> Premise Address: Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> . ,1� �' ` ``` Grout (from) (to) <br /> Inspector- <br /> Drilling rig type <br /> Permit No. Auger O.D. _ I.D. <br /> Completion - Stove pipe/chrisde box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: height <br /> Consultant <br /> Geologist A,C E-GROUND <br /> COWLEETCN CC+CSTY 30X <br /> �r'L�'T1CN <br /> SPECIAL PERMIT INFO.$�xl ► - <br /> prcc.•t <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - ft- <br /> ft. <br /> :r. <br /> v � o <br /> O <br /> SAMPLING sloroj = c <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> tt. '� — tt• <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) Casing type <br /> Storage Location Blank fr. Screen —fr• <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/ ii ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) — <br /> Type of method <br /> EH 29 29 <br />