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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 p <br /> ABOVE-G rR CUN D C4-ASTY-Box <br /> CO W LETiO N COWPLETICN <br /> SPECIAL PERMIT INFO. Gr°urd Suf'ce <br /> Distance to sewer line groc <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - n <br /> - <br /> - M <br /> C <br /> O <br /> SAMPLING ilornd <br /> tocicn _ <br /> Holding Temperature _ <br /> Method — <br /> Screenin;Method :sm <br /> Tracking Shcet - (y/ n) r: _ <br /> it. . <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/gravcl <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 />