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,► 1 <br /> MONITORING WELL INSTALLATION REPORT <br /> CONS N <br /> Date: <br /> Total Depth _(to) <br /> Premise Address: Screen Length (from) (to) <br /> Filter Pack Urom)------(to) <br /> Well No.: Bentonite (from)_-- <br /> Grout (from) _(to) <br /> Inspector: Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: he; <br /> Consultant re ' <br /> Geologist ABOVE-GRCUND �Zty.acx <br /> CO MpLF_f{CN Gpt,{pt„ncN <br /> Ground Sufact <br /> SPECIAL PERMIT INFO• orout <br /> Distance to sewer line _ (t. <br /> Domestic well on site - (Y/ n) ry, <br /> if yes, location and distance - It — <br /> M <br /> C <br /> - O <br /> SAMPLING toricn — A <br /> = gaud pxk <br /> Holding Temperature <br /> Method — <br /> Screening Method <br /> Tracking Sheet - (y/ n) <br /> SPOILS <br /> • ATE IALS/DEVELOPMENT <br /> Storage Method <br /> Contamination Noted - (y/ n) Casing type --------- h, <br /> Storage Location Blank ft. Screen <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravcl <br /> Depth to water Filter Pack type/size <br /> Mix Ratios— Surge Block: - (Y/it) <br /> Installation Method Discussed with geologist: - (y/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />