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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/chrisde box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> 1Fn7 ,F height <br /> Consultant <br /> Geologist <br /> ABOVE-GRMNO GF¢ii,STY30x <br /> �I��pN cUMPLETICN <br /> SPECIAL PERMIT INFO. Groord Stzfxs <br /> Distance to sewer line arwt <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - <br /> ft. <br /> h. <br /> — m <br /> = c <br /> — c <br /> SAMPLING �lorai <br /> socicn <br /> Holding Temperature = vd F <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 fr. 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 />