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MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> CON_ STRU�ON <br /> Premise Address: <br /> Well No.: Total Depth <br /> Screen Length (from) <br /> Inspector,. Filter Pack (from)—(CO) <br /> Bentonite (fiom)-- <br /> Permit No. Grout (from)--(to)�— <br /> Drilling rig type —�--(LO) <br /> Auger O.D. <br /> Drilling Company Completion - Stov— e— pi— p�/��ID. <br /> n box <br /> Ccircle one) <br /> Driller: <br /> Consultant casingheight <br /> Geologist - v <br /> A°avE-GROUND <br /> SPECIAL PERMIT INFO. CONFLETiONCOMPLt s71 30X <br /> G=r4 Stxtaca CCN <br /> Distance to server line <br /> Domestic well on site - (y—/n—)— Orc-'t <br /> If yes, location and distance - <br /> It. <br /> h. ft. <br /> SAMPLJNG = e <br /> c <br /> Holding Temperature tocicn <br /> Method <br /> Screening Method = Pawtya�c <br /> Tracking Sheet - (y/n ) <br /> Y. <br /> SPOILS <br /> Storage Method <br /> Contamination Noted • (y/n) MATERiALS/DEVE[OPMENT <br /> Storage Location <br /> Casing type <br /> GROUI7NG Bloaekze& Screen h• <br /> Bags cement <br /> Depth to water Euckets bentonite <br /> Mix Ratios Bags sand/gravel <br /> -installation Method Filter Pack type/size <br /> Quantity installed Surge Block: - (y/n ) <br /> Discussed with geologist: - (y/n ) <br /> EH 29 29. Type of method <br />