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MONITORING WELL INSTALLATION REPORT <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/christie box (circle one) <br /> Drilling Company: <br /> Driller: _ casing <br /> height <br /> Consultant <br /> Geologist _— ._ V <br /> ABOVE-GROUND —7 <br /> COkFLET;ON C7-fA38T WX <br /> SPECIAL PERT INFO. Ground Surface CC�iPLETION <br /> MI <br /> Distance to sewer line X, Qt0C1t <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - n <br /> V I <br /> = m <br /> O <br /> C <br /> SAMPLING = <br /> alottvd — � <br /> sacicn <br /> Holding Temperaturevaviw P <br /> ack <br /> Method <br /> Screening Method <br /> Tracking Sheet ( y/ n ) _ <br /> SPOILS <br /> Storage Method _ MATERIALS/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 />