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MONITORING WELL INSTALLATION REPt-vkT <br /> Date: CONSTRUCTION <br /> Premise Address:_ Total Depth <br /> �� # Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> J Bentonite (from) (to) <br /> Inspector: —�^~��I 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 /> 17Theight <br /> Consultant //�� � <br /> 99 <br /> Geologist 4�- AWI N —EFW—f <br /> ABOVE-GROUND <br /> CHRSSTY43OX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Suiacs <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> ft. <br /> If yes, location and distance - <br /> C <br /> C <br /> SAMPLING sbttsd <br /> s•c�on "x• —_ <br /> Holding TemperaturegravW <br /> Method "" _ A <br /> ack <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> ..r..�r.ft. ft. <br /> SPOILS <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 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 /> Type of method <br /> EH 29 29 <br />