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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSIRUCnON <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 We <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cliristie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant IV <br /> Geologist <br /> ABCYE-GaCUND CHR STY-aOX <br /> COW LETC N CC*APt..ErC N <br /> SPECIAL PERMIT INFO. Carx:nd Sul"'e —� <br /> Distance to sewer line <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - ft <br /> i O <br /> V <br /> O <br /> O <br /> SAMPLING <br /> Holding Temperature _ = 72 V1;_ack <br /> Method = <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) _— <br /> SPOILS <br /> Storage Method MATEFUALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen �• <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 />