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MONITORING WELL INSTALLATION REPORT <br /> Date: �� �� CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: d- 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/clu•istie box (circle one) <br /> Drilling Company: <br /> Driller: � casing <br /> hei. ht <br /> Consultant J l t <br /> Geologist <br /> AWVE-GRCUND CHMM-WX <br /> COMPLETCN COMPLEMN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - ft- <br /> ft. <br /> SAMPLING fj�� slorai <br /> r- 1 socicn <br /> Holding Temperature <br /> :a. V'V'W Pack <br /> Method '— <br /> �Yd — <br /> Screening Method se <br /> Tracking Sheet - (y/n) <br /> ft. — fL <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 /> GROU'T'ING 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 />