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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 --- ABOVE-GROUND <br /> CO hrP LET}O N CNR:STY-c30 X <br /> COMPLETiCN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - ( y/ n ) ft. <br /> If yes, location and distance - ft. <br /> a o <br /> - O <br /> SAMPLING slotted :? <br /> Holding Temperature " _ <br /> : ._ gravel Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet (y/ n ) _ 4. _— <br /> fit. IF <br /> SPOILS <br /> Storage Method ___ MATERIALS�EVELOPMENT <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 />