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MONITORING WELL INSTALLATION REPORT <br /> a <br /> Date: —CONSTRUCTION F <br /> Premise Address: * { M 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 rig~type <br /> Permit No. ' Augcr O.D. i I.D. <br /> Completion - Stove pige/christie box (circle one) <br /> Drilling Company: <br /> Driller: -` casing <br /> height <br /> Consultant '4 <br /> Geologist ` <br /> - ABCVE-GROUND CHSZTY-SOX <br /> CONFL rTON <br /> . COMPI.EnCN <br /> SPECIAL PERMIT INFO, G=rid Sufan <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - <br /> tt. <br /> w <br /> SAMPLING = s <br /> iiorod C <br /> Holding Temperature N — <br /> Method >: 72 W pacts <br /> Screening Method <br /> Tracking Sheet ={ y/ n ) ` ' — <br /> .R <br /> SPOILS i <br /> Storage Method \, MATERIALS EVEL.OPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location' Casing type <br /> Blank fr- 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 gcologist: - (y/ n ) <br /> EH 29 29 Type of method <br /> 1 I ° <br />