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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 <br /> from) (to)Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/duistie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant V <br /> Geologist 75, T <br /> E-GACUND CF6775TY80X <br /> COMPLETION COMPLE71CN <br /> SPECIAL PERMIT INFO. Gnxmd Sulam <br /> Distance to sewer line <br /> prcut <br /> Domestic well on site - (y/ n ) It <br /> If yes, location and distance - ft. <br /> R. <br /> yi <br /> - <br /> SAMPLING <br /> doCad � <br /> 4 c - <br /> Holding Temperature <br /> Method — pavw Pack <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <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 />