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MONITOPING 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: <br /> __— casing <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE-GROUND <br /> COMPLETION CI-IRZ'rY-80X <br /> SPECIAL PERMIT INFO. GroundSaiace COMPLETION <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) l <br /> If yes, location and distance - <br /> ft. <br /> - O <br /> SAMPLING — o <br /> sbtted _— c <br /> 1it70r1 iN <br /> Holding Temperature <br /> Method tip <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: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> EH 29 29 Type of method <br />