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MONITOPING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: -- Fiiter 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 /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> Driller: _ _ '�(-1 casing <br /> height <br /> Consultant <br /> Geologist <br /> - — ABOVE-GROUND <br /> COWLETlON C-SZ Y-60X <br /> SPECIAL PERMIT INFO. pard Surface COMPLETION <br /> Distance to sewer line gro(A <br /> Domestic well on site - (y/n ) <br /> If yes, location and distance - ft. <br /> ft. <br /> -- ft. — <br /> = m <br /> Nr C <br /> SAMPLING — a <br /> s to tied c <br /> — m <br /> tec5on — <br /> Holding Temperature _ <br /> Method — agrivo�pack <br /> Screening Method —_ <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method _ M_ ATERIALS/DEVELOPMENT <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 water _. 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 />