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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/cluistie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: � height <br /> Consultant <br /> Geologist — AE O -GRCVND <br /> L-ETIO N Ct-RSTY-30X <br /> Cb hP <br /> CO&APUEMCN <br /> SPECIAL PERMIT INFO. Ground Sulw ..� <br /> prod <br /> Distance to sewer line — <br /> Domestic well on site - ( y/ n ) it• <br /> If yes, location and distance - n <br /> tt. <br /> `. <br /> — o <br /> SAMPLING •IorQ.i <br /> soden — <br /> Holding Temperature <br /> Method <br /> .rc <br /> Screening Method ' <br /> Tracking Sheet - (y/ n ) <br /> r ft. <br /> SPOILS <br /> Storage Method MATE RIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank—ft- Screen ft. <br /> Slot size_ <br /> GROUPING 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/ li ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) — <br /> Type of method <br /> EH 29,29 <br />