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_ woI NITORING WELL INSTALLATION REPO �. T <br /> r _ f <br /> Date: f '1 <br /> CONSTRUCTION <br /> p2 <br /> Premise Address 7 �� _��'[ ��'L Total Depth <br /> L/ _ Screen Length (from) (to) <br /> Well No.: x 7 r -..k Filter Pack' k (from) (to) <br /> �&"'"`�`��I � ' Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. k _' `Auger O.D. '4 I.D. <br /> Completion -'stove pipe/christie box (circle one) �"- <br /> i <br /> Drilling Company: <br /> Driller: 4 casing <br /> Rla�la- <br /> „ height <br /> IT7 <br /> Consultant <br /> Geologist . ' a tix3 ; ;� T <br /> G <br /> ABOVE- ROiJNQ • __ <br /> ._ COMPLETION =`1COMPLETION <br /> SPECIAL PERMIT INFO. ; Ground Surface �;.:....r.�..,.� <br /> Distance to sewer line gram <br /> Domestic well on site - (y/ n } ft. <br /> If yes, location and distance - , <br /> f. <br /> }r y E <br /> SAMPLING slotted ' <br /> Holding Temperature <br /> Method '' = I&vW pack <br /> Screening Method <br /> Tracking Sheet - (y/ n) <br /> ft. MIft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELO_PM_E_NT �. <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> A SIot 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 /> a <br /> EH 29 29 <br />