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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/clu-istie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> T he_ght <br /> Consultant IV <br /> 7// <br /> Iq <br /> _q <br /> Geologist V <br /> ABOVE-GACUND CtRfSTY-80X <br /> COMPLETION CCMPLE71CN <br /> SPECIAL PERMIT INFO. Ground su lacs <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) ft. <br /> If yes, location and distance - ft- <br /> - R- <br /> •F � M <br /> SAMPLING <br /> ilot:a.i C <br /> soden "— <br /> Holding Temperature <br /> Method �- = VIYW D� <br /> >: <br /> Screening Method :r = <br /> Tracking Shcet - ( y/ n ) — <br /> ft. <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 method <br /> EH 29 29 <br />