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MONITORING WELL INSTALLATION REPORT <br /> Date: _ CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: _ Filrer 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 /> 1 height <br /> Consultant <br /> Geologist <br /> A20VE-GROUND <br /> C0WLET}ON C>-{F'i M-aOX <br /> COMPLE7CN <br /> SPECIAL PERMIT INFO. Gcourd SLeaca <br /> Distance to sever line groul <br /> Domestic well on site - (y/ n ) ft <br /> If yes, location and distance - <br /> C <br /> SAMPLING — <br /> slotted — m <br /> sacdon — � <br /> Holding Temperature _ _ grlvq�pack <br /> Method ' '- <br /> -- i _ <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 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 method <br /> EH 29 29 <br />