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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 /> Dolling Company: <br /> Driller: casing <br /> height <br /> Consultant <br /> —q <br /> Geologist •- v <br /> ABOVE-GACUND GNASS'T�(-SOX <br /> COMPLETION COMPL_EMN <br /> SPECIAL PERMIT INFO. Ground Skxfwt <br /> Distance to sewer line °(eL4 <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - ft. <br /> >: YO <br /> SAMPLING <br /> slot•.ai <br /> soden <br /> Holding Temperature _ <br /> ack <br /> Method = RaY�F <br /> Screening Method .2- <br /> Tracking <br /> Tracking Shcet - ( y/ n ) <br /> 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 with geologist: - ( y/ n ) <br /> Type of mcdlod <br /> EH 29 29 <br />