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MONITORING WELL INSTALLATION REPORT <br /> CONSTP-UCnON <br /> Date• 1 � <br /> v _ Total Depth � ��� (to)�� <br /> Premise Address: Screen Length (from) <br /> Well No.: <br /> Filter Pack (from) <br /> �-- Bentonite <br /> Grout i (from) (to)� <br /> Inspector. Drilling rig type <br /> Auger O.D. LD. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: . <br /> casing <br /> Driller. �� =�'x height <br /> Consultant <br /> Geologist �� M' ASO'f1=���ND CkfF M Y-BOX <br /> CQMPLEfION CCMPL=—T10N <br /> Ground Sartaca i <br /> SPECIAL PERINFO. <br /> grout <br /> Distance to sewer line ft. <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - �� . <br /> a <br /> SAMPLING Z.+ <br /> ---�- toclen �-1 <br /> Holding Temperature <br /> y�2"Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/n) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT &6 <br /> Contamination Noted - {y/ n) Casing type <br /> Storage Location Blank ft. Screen----.ft. <br /> Slot size <br /> GROUTING ' Bags ce nt <br /> Buckets cntonite <br /> Depth to water ��-5�� Bags s d/gravel <br /> Mix Ratios Filter ack type/size <br /> Installation Method Sorg Block: - (y/ n ] <br /> Quantity Installed Dis ussed with geologist: - ( y/ n) <br /> Type of method <br /> EH 29 29 <br />