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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 /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> Driller: casing <br /> height <br /> Consultant T <br /> Geologist T <br /> ABOVE-GROUND <br /> COMPLETION CNRMY-SQX <br /> SPECIAL PERMIT INFO. Ground Swiaca COMPLETION <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) • •,— . <br /> If yes, location and distance - <br /> • <br /> d m <br /> SAMPLING — <br /> slattad C <br /> sac�on _ �$ <br /> Holding Temperature ;r <br /> Method -'c= VIVV4 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 t 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 /> EH 29 29 Type of method <br />