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„,,JNITORING WELL INSTALLATION REPG,..e <br /> Date: j..� t .. CONSTRUCTION <br /> Premise Address:�3 �( E ( Total Depth Jas <br /> Screen Length (from) �S (to) 1 <br /> Well No.: Filter Pack (from) 85” (to)_ / <br /> Bentonite (from) /3 (to) / <br /> Inspector. Grout (fro ) Tr�(to) <br /> P ��`� Drilling rig type <br /> Permit No. <br /> Auger O.D. /0" I.D. <br /> Drilling Company:_ . Completion - Stove pipe/ !sue b x circle one) <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE-GRCUND t7rjr� <br /> COMRL.EflON <br /> SPECIAL PERMIT INFO. pend gur{ay <br /> Distance to sewer line >_56 / grout <br /> Domestic well on site - (y/ ri 1 <br /> If yes, location and distance V <br /> aN w <br /> SAMPLING : = s <br /> secicn <br /> Holding Temperature <br /> Method <br /> Q"r°�pack <br /> Screening Method <br /> Tracking Sheet (y/ n } _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - y/ n <br /> Storage Location—&A Casing type <br /> Blank ft. Screen ft. <br /> Slot size �Z <br /> GROU 1NG Bags cement <br /> 1 Buckets bentonite_ cL <br /> Depth to water o�3 g Bags sand/gravel <br /> Mix Ratios D Filter Pack type 'zed / L <br /> Installation Method Surge Block: - y/ n ) <br /> Quantity Installed Discussed wig ologist: `- / n ) <br /> Type of methods <br /> EH 29 29 U,_.._._ �. <br />