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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. <br /> _ (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: casing <br /> height <br /> Consultant <br /> Geologist .� V <br /> ABOVE-GROUND —q <br /> COMPLETION CNAZ Y-$OX <br /> SPECIAL PERMIT INFO. GroundSurixe COMPLETION <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft. <br /> ftft' <br /> 'a <br /> = m <br /> _ a <br /> = m <br /> SAMPLING — o <br /> slotted — c <br /> sacaon <br /> Holding Temperature <br /> Method _ — gmyw Pack <br /> Screening Method _ <br /> Tracking Sheet - ( y/ n ) _ <br /> SPOILS <br /> Storage Method M_ ATERIALS/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 /> EH 29 29 Type of method <br />