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MONITORING WELL INSTALLATION REPORT <br />Date: <br />CONSTRUCTION <br />Premise Address: <br />Total Depth <br />Screen Length (from)' (to) <br />Well No.: <br />Filtet Pack (from) (to) <br />Bentonite' (from) (to) <br />Inspector: <br />Grout (from) (to) <br />Drilling rig type <br />Permit No. <br />Auger O.D. - ---- -- - I.D. <br />Completion - Stove pipe/christie box (circle one) <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 />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 />11 <br />casing <br />height <br />ABOVE -GROUND <br />COMPLETION <br />Grour)dSurlaca <br />grout <br />= m _ <br />' � m <br />C <br />O <br />�lattad — c <br />taction — <br />gr+ P -,C11 <br />-,. — <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 />_Surge_Block--__(_Y_Ln-)---- <br />Discussed <br />n_) ---_Discussed with geologist: - (y/ n ) <br />Type of method <br />17, <br />