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• Y <br /> 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. Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE-GRGUND <br /> COWLS CN Ci ON <br /> CCMPLEMPLETiCN <br /> SPECIAL PERMIT INFO. G=nd S�'� <br /> Distance to sewer line stat <br /> Domestic well on site - (y/ n ) ft. <br /> If yes, location and distance - ft, <br /> ft. <br /> r <br /> C <br /> O <br /> SAMPLING dorsi <br /> s 'en — <br /> Holding Temperature gaud yat <br /> Method = <br /> Screenin;Method <br /> Tracking Sheet - (y/ n) <br /> ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen fr- <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 />