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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from)_(to)- <br /> Inspector: <br /> from) (to)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 /> Consultant <br /> YET height <br /> Geologist ._ <br /> ABOVE-GROUND <br /> COMPLETION CHMM-SOX <br /> SPECIAL PERMIT INFO. GroundSurfxa COMPLETION <br /> Distance to sewer line C� <br /> Domestic well on site - (y/ n ) n <br /> If yes, location and distance - <br /> n. <br /> ft. <br /> = m <br /> d <br /> = m <br /> SAMPLING <br /> slotted _ S <br /> saricn <br /> Holding Temperature _ P <br /> Method <br /> ack <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 />