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MONITORING WELL INSTALLATION REPORT <br /> Date: � <br /> CONS TRUE PION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No,, Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> . 1� '` Grout (from) (to) <br /> Inspector' <br /> Drilling rig type <br /> Permit Na. Auger O.D. I.D. <br /> Completion - Stove pipe/clu•istie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: t height <br /> Consultant <br /> Geologist AS;;YE-Gi1CUh1D <br /> GO h4'!.._cTlO N Ch�tISTY-30X <br /> GOMPt_EnCN <br /> SPECIAL PERMIT INFO. <br /> grcxrt <br /> Distance to server line } <br /> Domestic well on site - {y/ n ) •ft, <br /> If yes, location and distance - •.It• <br /> C <br /> O <br /> SAMPLING �iorai <br /> sacicn <br /> Holding Temperature = QnV1W Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - {y/ n 1 — <br /> SPOILS <br /> Storage Method MATERIALSIDEVEI.OPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen K• <br /> Slot size <br /> GROUTING 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/ it ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />