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MONITORING WELL INSTALLATION REPORT <br /> Date: CONS N <br /> Total Depth <br /> Premise Address: <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/cltristie box (circle one) <br /> Drilling Company: <br /> —:F <br /> casing <br /> Driller:' he±ght <br /> Consultant <br /> Geologist ABOVE-GRCUND CILG StY-BOX <br /> covet-EMON COf 1PLEMN <br /> Gmun d Suiact <br /> SPECIAL PERMIT INFO. <br /> Aran <br /> Distance to sewer line _tt <br /> Domestic well on site - (y/ n) tt. <br /> If yes; location and distance - R <br /> Y� <br /> — o <br /> SAMPLING slonni <br /> socicn —_ <br /> Holding Temperature <br /> Method ° — <br /> Screening Method =_ <br /> Tracking Sheet - (y/ n) = it. <br /> tt. <br /> SPOILS <br /> MATERI ALS/DE V ELOPMENT <br /> Storage Method <br /> Contamination Noted - (y/n) Casing type f <br /> Storage Location Blank fr. 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/n) <br /> Installation Method Discussed With geologist: - (y/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />