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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Well No.: Screen Length (from)' _(to) <br /> Filtei Pack (from) (to) <br /> Bentonite' (from), ` (to) <br /> Inspector: Grout (from) <br /> (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: <br /> Completion- Stove pipe/chnstie box (circle one) <br /> Driller: casing <br /> Consultant height <br /> Geologist <br /> ABOVE-GROUND <br /> COMPLETION C}iA15T7$OX <br /> SPECIAL PERMIT INFO GCOMPLETION <br /> Ground Surface <br /> Distance to sewer line ➢rout <br /> Domestic well on site - (y/n) <br /> IF yes, location and distance - _ft. <br /> — o - <br /> SAMPLING c <br /> elo fled - — c <br /> Holding Temperature <br /> s- con A� HE S <br /> Method a = vlvt4 Pack <br /> Screening Method <br /> Tracking Sheet - (y/n) • <br /> ft. = Ltt. <br /> SPOILS <br /> Storage Method MATERL4LS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> GROUTING Slot size <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios Bags sand/gravel <br /> InstallationMethod Filter Pack type/size <br /> Quantity Installed Discussed with geologist: - (y/n) <br /> EH 29 29 Type of method <br />