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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 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 /> height <br /> Consultant <br /> 7 T <br /> Geologist ---- ABOVE-GRCCIND <br /> COh�F'L..�TfON C»i3STY-30X <br /> COMPLErCN <br /> SPECIAL PERMIT INFO. Crourd Sumacs <br /> proof <br /> Distance to sever line <br /> - B/z, <br /> Domestic well on site ( y/ n ) ��,ft. <br /> If yes, location and distance - ft. <br /> V <br /> C <br /> O <br /> SAMPLING 810r.ad <br /> aocicn _ <br /> Holding Temperature gavel Pact <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> ft, tI. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location _ Casing type <br /> Blank ft. 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 geologist: ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />