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MONITORING WELL INSTALLATION REPORT <br />Date: CONSTRUCTION <br />Premise Address: Total Depth <br />Screen Length (from) ' (to) <br />Well No.: Filtet 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 />Drilling Company: <br />Completion - Stove pipe/chnstie box (circle one) <br />. <br />Driller: <br />casing <br />height <br />Consultant <br />Geologist <br />ABOVE -GROUND <br />comPLETION CNAISTY-BOX <br />COMPLETION <br />SPECIAL PERMIT INFO. Ground Surface <br />Distance to sewer line proof <br />Domestic well on site - ( y / n ) <br />If yes, location and distance - ft- <br />ft, ft. <br />SAMPLING — o <br />slatted — c <br />&- t a n _ <br />Holding Temperature <br />Method peva► pack <br />Screening Method = <br />Tracking Sheet - ( y/ n) <br />SPOILS <br />Storage Method <br />Contamination Noted - ( y / n ) <br />Storage Location <br />GROUTING <br />Depth to water <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />EH 29 29 <br />0 <br />MATERIALS/DEVELOPMENT <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 />---- <br />Discussed with geologist: - (y/ n ) <br />Type of method <br />