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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) CEO) <br /> - <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. Grout (from) (to) <br /> Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: � height <br /> Consultant <br /> Geologist Xgp -GRCJND <br /> COWL.FTION G}AiSTY BOX <br /> C:Ck.1PL.�TICN <br /> SPECIAL PERMIT INFO. '� Suite <br /> gra."t <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) tt. <br /> If yes, location and distance - h• <br /> ti. <br /> - C <br /> O <br /> SAMPLING ilorndsuccn — <br /> Holding Temperature Q"9I Pack <br /> Method <br /> Screening Method — <br /> Tracking Sheet - (y/ n) <br /> B• — tt. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) Casing type <br /> Storage Location Blank ft. Screenft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Filter Pack type/size <br /> Mix Ratios <br /> Installation Method Surge Block: - (y/ It ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />