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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 /> Auger O.D. I.D. <br /> Permit No. Completion -Stove pipe/christie box (circle one) <br /> Drilling Company% <br /> casing <br /> Driller• � T height <br /> I <br /> Consultant <br /> .Geologist ABOVE-GROUND CHRIM,BOX <br /> cohFLE171061 CWPLmcN <br /> Gmound Udacs <br /> PECIAL PERMIT INFO <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y/n} it. <br /> if yes,location and distance - �• <br /> a <br /> alai:" � <br /> SAMPLING secicn 3 , <br /> pack <br /> Holding Temperature <br /> Method <br /> Screening Metho <br /> Tracking Shcet - (y/n} r <br /> Storage Method A•l•EgIALS[DEVELOPMENT <br /> Contamination Noted- (y/n) Casing type <br /> Storage Location Blank _ft- Screen h• <br /> Slot size <br /> — <br /> Bags <br /> Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> AInstaliation Method Surge Block: - (y/n] <br /> Quantity Installed Discussed with geologist: - (y/n) <br /> Type of Incthod <br /> EH 29 29 <br />