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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: FIltet Pack (&om) (to) <br /> Bentonite' (from) (to) <br /> Inspector: Grout <br /> (from) (to) <br /> Drilling rig type <br /> Permit No. <br /> Auger 0,P,_ _. •�, <br /> Completion- <br /> Drilling Company: Stove pipe/cluistie box (circle one) <br /> -_: <br /> Drillez: i casing <br /> Consultant ` height ' <br /> Geologist _ <br /> ABOVE-GROUND <br /> COMPLETION CNR57Y-BOX <br /> SPECIAL PERMIT INFO COMPLETION <br /> Ground Surface <br /> Distance to sewer line D+ <br /> Domestic well on site - (y/n) <br /> out <br /> If yes, location and distance - g, <br /> h. <br /> :x <br /> SAMPLING <br /> dotted v. _ c <br /> txdon <br /> Holding Temperature — <br /> Method ;' = praysl pads <br /> Screening Method > _ <br /> Tracking Sheet - (y/n) <br /> SPOILS <br /> 4 <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> GROUTING Slot size <br /> Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack typesize <br /> Installation Method ___ ____ _ $prge-$lock:--_(-y_/na__ <br /> Quantity Installed -- <br /> Discussed with geologist: - (y/ n) <br /> EH 29 29 Type of method <br />