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I- <br /> •NITORING WELL INSTALLATION REPO* <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. T casing <br /> T height <br /> Consultant ` <br /> T <br /> Geologist ABOVE-GRCUND <br /> CONPLETCN COMPL-BOX <br /> CCMPLETICN <br /> SPECIAL PERMIT INFO. ®end Suiact + � <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) ft. <br /> If yes, location and distance - ft. <br /> ft. <br /> V p <br /> = a <br /> SAMPLING <br /> toc'cn — <br /> Holding Temperature = pnvel past <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen h. <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 />