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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from)' Cto) <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/chnstie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist ABOVE-GROCJND <br /> ' CO MF LET10 N GHAIS'I'1'-80X <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Sacs <br /> Distance to sewer line rout <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - <br /> ' ft, <br /> = m _ <br /> C <br /> p <br /> SAMPLING ilaCC� _ <br /> Holding Temperature = gnv,�4 Pack <br /> Method = <br /> Screening Method <br /> Tracking Sheet - (y/n) <br /> = M. <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 — <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br /> • <br />