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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: F;lter 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 /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> Driller: <br /> �(— Icasing <br /> 1 <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE-GROUND <br /> CO W LET}C N CHRISTY-BOX <br /> CC4, PLET CN <br /> SPECIAL PERMIT INFO. Ground Surfxa <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n ) <br /> If yes, location and distance - ft. <br /> ft. <br /> — — m <br /> SAMPLING — a <br /> slotted — c <br /> sacnon = a <br /> Holding Temperature <br /> Method V'V'EW Pack <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 ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth twater 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 /> EH 29 29 Type of method <br />