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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Well No.: Screen Length (from)' (to) <br /> 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 /> Drilling Company: Completion - Stove pipe/chnstie box (circle one) <br /> Driller: <br /> casing <br /> height <br /> Consultant ' <br /> Geologist .w �► <br /> ABOVE-GROUND <br /> CO wP LET{O N C}iR Z Y-BOX <br /> SPECIAL PERMIT INFO COMPLETION <br /> Ground Suriaco <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) <br /> If yes, location and distancexn. <br /> _ 'a <br /> • � m <br /> SAMPLING K• — o <br /> BIC — <br /> tacdon = <br /> Holding Temperature = <br /> Method = ;r2vs?pack <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: - <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> EH 29 29 Type of method <br />