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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 <br /> Geologist <br /> ABOVE-GRCUND <br /> COWLET10N C4-SZ7Y-BOX <br /> COMPLETICN <br /> SPECIAL PERMIT INFO. Ground Surtaca <br /> Distance to sewer line gran <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft. <br /> o <br /> q <br /> SAMPLING = a <br /> •lotted E <br /> sacdon —_ � <br /> Holding Temperature <br /> ws <br /> Method _ ` <br /> Screening Method _ <br /> Tracking Sheet (y/ n ) f <br /> St. ft. <br /> SPOILS <br /> Storage Method MATERIALS�EVELOPMENT <br /> Contamination Noted - (y/n ) <br /> Storage Location Casing type <br /> Blank ft. Screen fta <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 />