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MONITORING WELL INSTALLATION REPORT <br /> CONS N <br /> Date: <br /> Total Depth <br /> Premise Address: Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Grout (from) (to) <br /> Inspector. Drilling rig type <br /> Auger O.D. 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-GRCUND CNSZTY-Box <br /> coWL Tf ON ComPf—EnCN <br /> -- Grourd SLsfacs <br /> SPECIAL PERMIT INFO. <br /> prcut <br /> Distance to sewer line it. <br /> Domestic well on site - (y/ n) ft <br /> If yes, location and distance - tt <br /> :Z _ _ <br /> — w <br /> " = o <br /> — c <br /> — o <br /> IIOr.D� = C <br /> SAMPLING locicn <br /> Holding Temperature - lift. <br /> MethodScreening MethodTracking Sheet - (y/n) <br /> SPOILS <br /> MATERI AI-S/DEWI.OPMENT <br /> Storage Method <br /> Contamination Noted - (y/n) Casing type <br /> Storage Location B1 ft Screen��fr <br /> Slot size <br /> Bags cement — <br /> GROLITING Buckets ben[oni[e <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/ n ) <br /> Installation Method Discussed with geologist - (y/ n) <br /> Quantity Installed Type of method — <br /> EH 29 29 <br />