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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: cam;` Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from)_ (to) <br /> Bentonite (from) ([o) <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 /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant IV <br /> Geologist <br /> ABCVF--GAC,UND CHR*TY-BCX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. G=rd Surface <br /> Distance to sewer line grcut <br /> Domestic well on site - (y/ n ) ft. <br /> if yes, location and distance - <br /> � ft. <br /> m <br /> b <br /> SAMPLING <br /> aQc'icn � <br /> Holding Temperature <br /> Method <br /> Screening Method — <br /> Trackuig Sheet - ( y/ n ) <br /> tr. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> SIot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravcl <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 /> EIS 29 29 <br />