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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/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> + <br /> height <br /> Consultant '4 <br /> PTA —WVT <br /> Geologist �' �g�j � � � -- <br /> ABCVE-GRCUND C}iAiSTY-80X <br /> COMPLEETION COMPLEMCN <br /> SPECIAL PERMIT INFO. Grcund Surface <br /> Distance to sewer line Gf0"t <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - <br /> ft. <br /> "a a <br /> SAMPLING •lot•.v.! = c <br /> &oclen <br /> Holding Temperature = 71,,W <br /> Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> tt. — /utS & <br /> SPOILS !rry <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 metliod <br /> EH 29 29 <br />