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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/cluistie box (circle one) <br /> Drilling Company: <br /> Driller:' casing <br /> height <br /> Consulmn: <br /> Geologist A°OVE-GFICUND <br /> COMPLETION ChA:ST_=ncN <br /> COMPLEiICN <br /> SPECIAL PERMIT INFO. �—t=-d 9� —� <br /> pra=t <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) it. <br /> If yes, location and distance - n• <br /> n. <br /> - = o <br /> �lorai � <br /> SAMPLING tocicn = <br /> Holding Temperature <br /> Method <br /> Screening Method _ <br /> Tracking Sheet - (y/ n) _ <br /> SPOILS <br /> MATERI ALS/DEVF LOPMENT <br /> Storage Method <br /> Contamination Noted - (y/n) Casing type <br /> Storage Location Blank fr. Screen — <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Rados -- Surge Block: - (y/n) <br /> -�Installadon Method Discussed with geologist: - (y/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />