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4 <br /> _ONITORING WELL INSTALLATION REPO, <br /> f <br /> Date: CONSTRUC'T'ION <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}L -(to)�� <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> �D77``;; , Completion - Stove pipe/christie box (circle one) <br /> Consultant LZU" 4U - <br /> 4 <br /> Geologist std*-up <br /> SPECIAL PERMIT INFO. <br /> ABOVE-GROUND <br /> COMPLETION CHRISTY-BOX <br /> Distance to sewer line COMPLETION <br />. Domestic well on site - ( y/ n ) <br /> Ground Surisct <br /> If yes, location and distance - + <br /> ? <br /> ft. <br /> SAMPLING <br /> >_ m <br /> 0 <br /> Holding Temperature Owed d <br /> Method ' _ ") �seclon x w <br /> Screening Method voI <br /> r Tracking Sheet - (y/ n ) P <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> ' Contamination Notes - (y/ n <br /> Storage Location Casing type <br /> Blank ft. Screen fr. <br /> Slot size " <br /> Bags cement I <br /> GROUTING Buckets bentonite < <br /> Bags sand/gravel ' <br />.T Depth to water Filter Pack type/size <br /> Mix Ratios Surge Block: - ( y/ n ) <br /> Installation Method Cf. Discussed with geologist: - {y/�n ) <br /> Quantity Installed U Tyge-of-method s <br />