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MONITORING WELL INSTALLATION REPUmT <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/cliristie box (circle one) <br /> Drilling Company: <br /> Driller: _„_ casing <br /> height <br /> Consultant <br /> Geologist <br /> ABCVE-GRCUND <br /> COMPI.��T10N CNAISTY-30X <br /> COMPLEMN <br /> SPECIAL PERMIT INFO. Ground Sumacs <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - ( y/ n ) ft. <br /> If yes, location and distance - ft. <br /> ft. <br /> - 0 <br /> - C <br /> SAMPLING <br /> •lor.e'd � <br /> secicn — <br /> Holding Temperature <br /> Method = 9nYWPack <br /> Screening Method r __ <br /> Tracking Sheet - (y/ n ) — <br /> ft. — 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/ ti ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />