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0 MONITORING WELL INSTAL.L.ATION R*RT <br /> Date: <br /> CONSTRUCTION <br /> Premise Address: <br /> Total Depth <br /> Well No.: Screen Length (from) (to)�_ <br /> Filter Pack (from) (to)�_ <br /> Inspector: Bentonite (from) (to)_____ <br /> Grout (from) (to) _ <br /> Permit No. Drilling rig type _ <br /> Auger O.D. I.D. <br /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> Driller: <br /> casing <br /> Consultant height <br /> Geologist 17 —QVT <br /> 118 -GROUND <br /> SPECIAL PERMIT INFO. COM?LF-TION CHRZTY-SOX <br /> COMPLETION <br /> -----�-Ground Surface <br /> Distance to sewer line <br /> Domestic well on site - (y/n ) Dry <br /> If yes, location and distance - <br /> ' ft. <br /> .--_ft. ft• <br /> O <br /> SAMPLING — m <br /> _ c <br /> 0 <br /> slotted = c <br /> Holding Temperature a�c5on = B <br /> Method = <br /> Screening Method <br /> I&VW Pack <br /> Tracking Sheet - (y/n ) <br /> SPOILS ft. R• <br /> Storage Method <br /> Contamination Noted - (y/ n ) MATERIALS/DEVELOPMENT <br /> Storage Location <br /> Casing type <br /> Blank ft. Screen <br /> GROUTING Slot size <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios Bags sand/gravel <br /> Installation Method Filter Pack type/size <br /> Quantity Installed Surge Block: - (y/ n ) <br /> Discussed with geologist: - ( y/ n ) <br /> EH 29 29 Type of method <br />