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MONITORING WELL INSTALLATION REPO . <br /> Date: CONS N <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Well No.: Bentonite (from) (to) <br /> Grout (from) (to) <br /> Inspector. Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller F he_ght <br /> Consultant <br /> Geologist AgpyE GRCUND C}A ST1 30X <br /> OONV LETION COMPLEMN <br /> r�arwnd <br /> Sulxt <br /> SPECIAL PERMIT INFO. � <br /> T' prart <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) '/ ft. <br /> If yes, location and distance - l tt• <br /> ft. — <br /> 12 M <br /> C <br /> O <br /> itOtA <br /> SAMPLING �b socicn <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n) _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) Casing type <br /> Storage Location Blanc ft Screen —K• <br /> Slot size <br /> GROUT[NG Bags cement <br /> Buckets bentonite <br /> Depth to water ' / Bags sand/gravel,_ <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />