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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> i <br /> Premise Address: Total Depth �t <br /> Screen Length (from) �r ' -(to)–LL <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. <br /> Completion- Stove pipe/ sti box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist ._ T <br /> ABOVE-GROUND <br /> COMPLETION C>•fAfST 4= <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface - <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n ) ft <br /> If yes, location and distance - <br /> . <br /> ft. <br /> — m <br /> pp A <br /> SAMPLING <br /> slotted <br /> —�saction = <br /> Holding Temperature <br /> Method ' — �"�Pack <br /> Screening Method <br /> r•� <br /> Tracking Sheet - (y/n) <br /> r <br /> SPOILS 3 <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) 1) � �b <br /> Storage Location Casing type `T <br /> Blank 11 ft. Screen .�D ft. <br /> Slot size 0-04 O 6. -0 <br /> GROUTING Bags cement <br /> Buckets bentonite I <br /> Depth to water Bags sand/gravel o <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block:- / n ) <br /> Quantity Installed Discussed with geologist: - (0y n ) <br /> Type of method <br /> EH 29 29 <br />