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MONITORING WELL INSTALI-ATION REPORT <br /> CONS <br /> Date: <br /> Total Depth (to) <br /> Premise Address: Screen Length Urom) <br /> Filter Pack (from) (to) <br /> Well No.: Bentonite (from) (to) <br /> Grout . (from) (to) <br /> Inspector. Drilling rig type <br /> Auger I.D. <br /> Permit No. Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company. <br /> .' � casing <br /> Driller: height <br /> Consultant {� <br /> Geologist ABOVE•GRCt1ND ChAZ Y•oox <br /> co1,r tE:TfON COMPL—ncN <br /> Cx=rd SU1=1 <br /> SPECIAL PERMIT INFO. prat <br /> Distance to sewer line _! . <br /> Domestic well on site '- (y/ n) N. <br /> If yes, location and distance - ft <br /> _ - o <br /> 0 <br /> slar.� <br /> SAMPLING sot cn 's <br /> Holding Temperature <br /> Method _ <br /> Screening Method <br /> Tracking Sheet - (Y/ n) = ft. <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method <br /> Contaminadon Noted - (y/ n) Cazin g type <br /> Storage Location Blwik____fr_ Screen__-- f <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> MTX Ratios Surge Block: - (Y <br /> ,installation Method Discussed vrith geologist: <br /> Quantity installed Type of method <br /> EH 29 29 <br />