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ABOVE-GS MIND CMSTY-BOX CXACLETION COMPt...T1CN <br />Ground Surface <br />wait <br />ft. <br />ft. <br />0 <br />ft. <br />casing :ty height <br />GROUTING <br />Depth to water k <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />1 <br />MONITORING WELL INSTALLATION REPORT <br />Date: <br />Premise Address: <br />A"--e /--7 Well No.: <br />Permit No. <br />Drilling Company: <br />Driller: <br />Consultant <br />Geologist <br />SPECIAL PERMIT INFO. <br />Distance to sewer line <br />Domestic well on site- ( y / n) <br />If yes, location and distance - <br />SAMPLING <br />Holding Temperature <br />Method <br />Screening Method <br />Tracking Sheet - ( y / n ) <br />CONSTRUCTION <br />Total Depth <br />Screen Length (from) (to) <br />Filter Pack (from) (to) <br />Bentonite (from) (to) <br />Grout (from) (to) <br />Drilling rig type <br />Auger O.D. I.D. <br />Completion - Stove pipe/christie box (circle one) <br />Casing type <br />Blank ft. Screen ft. <br />Slot size <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />Surge Block: - ( y / ) <br />Discussed with geologist: - ( y / n) <br />Type of method <br />Inspector: I:4 • hi <br />SPOILS <br />Storage Method MATERIALS/DEVELOPMENT <br />Contamination Noted - ( y / n) - <br />Storage Location <br />EH 29 29