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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 /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: _ casing <br /> height <br /> Consultant 17T <br /> Geologist •� <br /> ABOVE-GROUND <br /> CCMPLET{ON Ct{R;STY 80X <br /> COMPLE71CN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line of Oul <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft' <br /> ft. <br /> �.ft. <br /> o <br /> — m <br /> SAMPLING <br /> slatted :,. c <br /> Holding Temperature <br /> Method _ Pac` <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 />