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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) (ta) <br /> Drilling rig type <br /> Permit No. Auger O.D. T.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant ` <br /> Geologist •- <br /> ABOVE-dROUND <br /> CHAiM4= <br /> cofPLF-TION! <br /> coMPt.FriON <br /> SPECIAL PERMIT INFO. G-cund surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n } 331- <br /> If <br /> fif yes, location and distance - ft• <br /> SAMPLING <br /> Holding Temperature <br /> Method gmV91 tack <br /> Screening Method 'w <br /> Tracking Sheet - {y/ n ) — <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) ► p /� U <br /> Storage Location - Casing type <br /> • r Blank ft. Screen <br /> Slot size 0.610 <br /> GROUTING' Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel ` <br /> Mix Ratios Filter Pack type/size ?'/-I- <br /> lnstallation Method Surge Block: - (y/n <br /> F Quantity Installed Discussed with geo gist: - ( y/ n ) <br /> ' <br /> EH 29 29 Type of method <br /> ti, <br />