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MONITORING WELL INSTALLATION REPORT <br /> CdA <br /> Date: / CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Aleq 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/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> —WT <br /> Consultant l <br /> �,JAA TGeologist •� <br /> ABOVE-GROUND CtiAMW43OX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surlwe <br /> Distance to sewer line ®rout <br /> Domestic well on site - (y/ n) n• <br /> If yes, location and distance - ft. <br /> SAMPLING slotted <br /> secdon —_ <br /> Holding Temperature :;'; ®_ W pack <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 />