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MONITORING WELL, INSTALLATION REPORT <br /> Date: <br /> CONSTRUCTION <br /> Premise Address: <br /> Total Depth <br /> Well No.: Screen Length (from)" (to) <br /> Filtet Pack (from) (to) <br /> Inspector: Bentonite' (from) (to) <br /> Grout (from) (to) <br /> Permit No. Drilling rig type <br /> Auger O.D. ID <br /> Drilling Company; Completion- Stove pipe/christie box (c— ircle one) <br /> Driller: <br /> casing <br /> Consultant height <br /> Geologist T <br /> ABOVE-GROUND T <br /> COMFLEf1ON CHRIT 4- OX <br /> SPECIAL PERMIT INFO. COMPLET ON <br /> Ground Stctace <br /> Distance to sewer line <br /> Domestic well on site • (Y/ngrout <br /> ) <br /> If yes, location and distance - <br /> ft, ft. <br /> 0 <br /> SAMPLING . F'- _ '-• c <br /> dotted __ c <br /> Holding Temperature wccn x� — <br /> µ; <br /> Method _ Viva?pack <br /> Screening Method <br /> Tracking Sheet - (y/n) <br /> SPOILS tt. <br /> Storage Method <br /> Contamination Noted - (Y/n) MATERIALS/DEVELOPMENT <br /> Storage Location <br /> Casing type <br /> Blank ft. Screen g, <br /> GROUTING Slot size <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios Bags sand/gravel <br /> Installation Method Filter Pack type/size <br /> Quantity Ins <br /> -j-talled--- ---.._ ----—Surge.-Block:_(-y_/_n-) <br /> Discussed with geologist; - (y/ n) <br /> EH 29 29 Type of method <br />