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MONITORING WELL INSTALLATION REPORT <br /> CONSTRUCTION <br /> Date: <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) Ro) <br /> Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: � height <br /> '9 <br /> Consultant –t•• <br /> Geologist ABOVE-GRCUND ��-SZ <br /> T <br /> CONFLETCN CCMPLcTICN <br /> SPECIAL PERMIT INFO. '� rd Sutxs + <br /> prcut <br /> Distance to sewer line <br /> Domestic well on site . (y/ n) tt. <br /> If yes, location and distance - h <br /> h. <br /> 4 - m <br /> _ w <br /> = E <br /> r2 <br /> 1�0t G� <br /> SAMPLING <br /> Holding Temperature <br /> Method = <br /> Screenin;Method —_ <br /> Tracking Shcet • (y/ n) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) Casing type <br /> Storage Location Bl ft Screen-------.ft- <br /> slot <br /> creen ft•Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Filter Pack type/size <br /> Mix Ratios <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n) <br /> Type of method <br /> EH 29 29 <br />