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MONITORING WELL INSTALLATION REPORT <br /> Date: y//'/ / CONSTRUCTION <br /> Premise Address:�4 Total Depth <br /> er Screen Length (from) (to) <br /> Well No.: Filter Pack (from)-(to)— <br /> Bentonite <br /> from) (to)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/ch istie box (circle one) <br /> Driller: casing <br /> 77 height <br /> Consultant '4 <br /> Geologist <br /> ABOVE-GRCUND <br /> COMPLETION CHRZTY-8oX <br /> SPECIAL PERMIT INFO. orourd Sulxy COMPLETICN <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) ft, <br /> If yes, location and distance - <br /> ft ft. <br /> SAMPLING <br /> 0 <br /> slorad = � <br /> t <br /> Holding Temperature <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 />