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MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> CONSTRUCTION <br /> Premise Address: <br /> Total Depth <br /> Well No.: Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Inspector: Bentonite' (from) (to) <br /> Grout (from) (to) <br /> Permit No. Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Company: Completion- Stove pipe/chm'stie box (circle one, <br /> Driller: <br /> casing <br /> Consultant height <br /> i <br /> Geologist <br /> ABOVE-GROUND <br /> COMPLETION CHRt iY-sax <br /> SPECIAL PERMIT INFO. COMPLETION <br /> 6rwnd SuAxa <br /> Distance to sewer line <br /> Domestic well on site - (y/n) grout <br /> If yes, location and distance - ft <br /> ft. ft. <br /> O <br /> SAMPLING <br /> 0 <br /> akttad — c <br /> Holding Temperature <br /> MethodgnvW= P <br /> ack <br /> Screening Method <br /> Tracking Sheet - (y/n) <br /> SPOILS ft _ ft <br /> Storage Method <br /> Contamination Noted - (y/n) MATERLALS/DEVELOPMENT <br /> Storage Location <br /> Casing type <br /> Blank ft. Screen ft. <br /> GROUTING Slot size <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios Bags sand/gravel <br /> Installation Method Filter Pack type/size <br /> - _ – <br /> Quantity Insfalled ----.._Siuge._$lock: <br /> Discussed with geologist: - (y/n) <br /> EH 29 29 Type of method <br />