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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 T <br /> Geologist _ T <br /> ABOVEGROUND CNA1SlY-BOX <br /> COMPLETION <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground SuAaca <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - <br /> ft. <br /> tt. <br /> _ m <br /> q <br /> - O <br /> C <br /> SAMPLING slatted <br /> wcdon — <br /> Holding Temperature <br /> Method 71VW PackScreening Method <br /> C: <br /> Tracking Sheet - (y/n) <br /> ft. <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 />