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i <br /> 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 /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> Driller: <br /> casing <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE-GROUND <br /> COMPLETION cHR*-ry-BOX <br /> SPECIAL PERMIT INFO. Groundgurlace COMPLETION <br /> Distance to sewer line pre t <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - • <br /> _ m <br /> — d <br /> = r <br /> SAMPLING <br /> slotted _ B <br /> s CL — <br /> Holding Temperature = P <br /> Method «: — graW <br /> Screening Method <br /> Tracking Sheet - (y/n) <br /> ft. = g- <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 />