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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: _ Grout (from)-(to)- <br /> Drilling <br /> from) (to)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 /> IffT <br /> height <br /> Consultant T <br /> T <br /> Geologist ABOVE-GROUND <br /> COMPLETION CMPLETION <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Ski°° <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) 1 ft, <br /> If yes, location and distance - tt. <br /> ft. <br /> _ m <br /> _ p <br /> � C <br /> SAMPLING slotted <br /> ascdon �• -- <br /> 9: <br /> Holding Temperature ___ 9rsval pack <br /> Method <br /> Screening Method , <br /> Tracking Sheet - (y/ n) f. <br /> SPOILS <br /> Storage,Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location— Casing type <br /> Blank ft. Screen fr• <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 /> ,0 <br />