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MONITORING WELL INSTALLATION RE_PC:xV— <br /> Date: /�So���, CONSTRUCTION <br /> Premise Address: 5 �� e �� Total Depth <br /> Screen Length (from) (to) <br /> Well No.: /kw Filter Pack (from) (to) <br /> / ,,�/ /� Bentonite (from) (to) <br /> tom <br /> Inspector: "15-�YC�C 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 /> � �- height <br /> Cons ant_ (�2l � <br /> Geologist <br /> ASOVE-GROUND <br /> COMPLETION CHRIST 4= <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surfact <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) �_ft. <br /> If yes, location and distance - ft. <br /> m <br /> SAMPLING <br /> slottod <br /> soon — <br /> Holding Temperature <br /> Method " __ 72vW Pack <br /> Screening Method '` <br /> Tracking Sheet - (y/n) -_ <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 typesize <br /> Installation Method Surge Block: - (y/ n) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />