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`.nONITORING WELL INSTALLATION REPL,,,e <br /> Date: z2� CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.- Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant —E <br /> �r <br /> Geologist T <br /> ABOVE-GROUND CHSMTY43OX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line ,/ <br /> Domestic well on site - (y/ n) 7.v <br /> If yes, location and distance - ft. <br /> "a' o <br /> SAMPLING slorad <br /> sadcn — <br /> Holding Temperaturepack <br /> Method I <br /> �vdScreening MethodTracking Sheet - (y/ n ) `T44 <br /> . ~ t:. <br /> SPOILS C � �n.0 <br /> Storage Method $ $ MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water 2-0 � 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 /> EH 29 29 LVk-5 5�.. CL<D <br /> Type of method <br />