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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. 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 /> I FrI height <br /> Consultant -i <br /> Geologist - T <br /> ABOVEGACUND GhR 5TY 30X <br /> COWLEiiON C MPLEMN <br /> SPECIAL PERMIT INFO. Crwrd S� <br /> Distance to sewer line drat <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - ft <br /> ft. <br /> = c <br /> — a <br /> SAMPLING slored <br /> soc'cn - —_ <br /> Holding Temperature <br /> Method _ <br /> Screenin;Method — <br /> (y/ n ) <br /> Tracking Sheet - <' <br /> — '• <br /> ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Locadon Casing type <br /> Blank fr. Screen K• <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonire <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 />