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MONITORING WELL INSTALLATION REPORT <br /> Date•, b CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: ' Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: /v + ` Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion- Stove pipe/ch ristie box (circle one) <br /> Drilling Company- <br /> casing <br /> casing <br /> D <br /> � � height <br /> Consultant <br /> GeologiCa-99M43OX <br /> COI FLMON c xAPLEnoN <br /> PECIAL P T INFO. aaurd Surf <br /> proof <br /> Distance to sewer line <br /> Domestic well on site- {y/n) ��• <br /> if yes, location and distance - M <br /> e <br /> � = s <br /> SAMPLING slora.� <br /> secicng <br /> Holding Temperature wave,POCK <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/n) — <br /> OPUS <br /> Storage Method MATER16L aEVELOPMENT <br /> Contamination Noted- (y/n} <br /> Storage Location Casing type_ <br /> Screen �• <br /> Slot size, <br /> GROUTING nags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack typesize <br /> Surge Block: - (y/n <br /> Installation Method } <br /> Quantity Installed-MethDiscussed with geologist: - (y/n) <br /> Type of method <br /> EH 29 29 <br />