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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 /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist <br /> —- ABOVE-G R CUND <br /> COMP LET{O N CHR ISTYW X <br /> SPECIAL PERMIT INFO. Ground Sud we COMPLETION <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) 1 <br /> If yes, location and distance - 7 n• <br /> Y4' m <br /> SAMPLING ` <br /> slotted � <br /> sacton '— <br /> Holding Temperature <br /> Method = 71'�Pad< <br /> Screening Method <br /> Tracking Sheet - ( y/ n4. <br /> ) _ <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 Bas sand/ <br /> gravel <br /> gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> EH 29 29 Type of method <br />