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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. e Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company. <br /> � casing <br /> Driller: � height <br /> ConsultantVTA <br /> Geologist 711, <br /> K-_o; E-GRCUND <br /> CONPLETION ChA:STY 30X <br /> COt.{r't="TICK <br /> SPECIAL PERMIT INFO. Ground Suiac' <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) It, <br /> If yes, location and distance - <br /> _ ft. <br /> M <br /> - C <br /> � O <br /> SAMPLING •lord = � <br /> Holding Temperature e = ¢avvtpaac <br /> Method <br /> Screenin;Method = <br /> Tracking Sheet - (y/ n ) _ — <br /> ft. V J — tt. <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 viith geologist: - (y/ n ) <br /> Type of method — <br /> EH 29 29 <br />