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•MONITORING WELL INSTALLATION REP*r <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Well No.: Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. Grout (from)-(to)- <br /> Drilling <br /> from) (to)Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: Completion - Stove pipe/cluistie box (circle one) <br /> Driller: casing <br /> Consultant T=YJ height <br /> � <br /> Geologist T <br /> ABOVE-GACQND <br /> COWLS CN C7i8ISTY-80X <br /> SPECIAL PERMIT INFO. GroundCCWLErCN S�rfacs <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - It. <br /> • � tt. <br /> SAMPLING — o <br /> donod = c <br /> soden <br /> Holding Temperature = <br /> Method <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/ tt ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> EH 29 29 Type of method <br />