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\-MONETORING WELL.INSTALLATION REPCr.:I' - <br /> Date:.,FlJ 1 q CONSTRUCTION <br /> Premise Address: �e*?Z s ' 4:-,p Total Depth <br /> Screen Length (from) (to) <br /> Well No.: /a•,a� ��- � �'r Filter Pack (from) (to) <br /> Bentonite (From) (to) <br /> Inspector _ Grout (From)_. _ (to) <br /> .Drilling rig type <br /> Permit No. Auger O.U. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casinq <br /> Driller: - ,F hezcht <br /> Consultant - <br /> Geologist <br /> A COVE-GRLUNO CF-ASTY-3OX <br /> CONPLMON C.OMPt 73ON <br /> SPECIAL PERMIT INFO. mrd 5af'CO <br /> grcut <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) tt. <br /> If yes, location and distance - ft. <br /> f#. <br /> M <br /> SAMPLfNG ' <br /> s xic n <br /> Holding Temperature <br /> Method s <br /> Screenin;Method ' — <br /> Tracking Sheet - (y/ n) <br /> SPOILS <br /> Storage Method MATERIALS EVEI'OPMENT <br /> Contamination Noted - (y/n) <br /> - Storage Location Casing type � <br /> Blank ft. Screen <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mik Ratios Filter Pack type/size <br /> isstalIation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed vrith geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />