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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-GROUND <br /> CC MP LET{O N CMA tSTY-80X <br /> SPECIAL PERMIT INFO. Ground SurfaceCGMPL!_TION <br /> Distance to sewer line Grp <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - n <br /> _ — a <br /> = m <br /> = m <br /> SAMPLING = ° <br /> slotted — <br /> s�on <br /> Holding Temperature = P <br /> ack <br /> Method _ — <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) ` _ <br /> ft. "v = I F <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 />