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m J MONiTOMNG,WELL.INSTALLATTON R RT <br /> Date <br /> 1� Y - CONSTRUCTION <br /> ! r - <br /> Premise Address: U-7 S `�—f f Total Depth <br /> Y t Screen Length (from) - (to) <br /> Well No.: Filter Pack (from) (to) <br /> -�Bentonite from (t.o <br /> ) <br /> Inspector: Grout (from).. (to) <br /> Drilling rig type <br />_ Permit No. Auger O.D. . I.D. <br /> v Completion- Stove pipe/christie box (circle one) <br /> ' Drilling Company: <br /> Driller: casing <br /> height: -- ....1 . <br /> Consultant <br /> Geologist <br /> ABOVE-GROUND <br /> CaMPLE7iON CtiFif57Y-6aX <br /> COMPl.EnCN <br /> SPECIAL PERMIT INFO. _ . . Ci=rid.Sudace , <br /> Distance to sewer line - - grout <br /> Domestic well on site - {y/n ) <br /> If yes, location and.distance <br /> s SAMPLING sbttod ys <br /> kt sac�on fi <br /> Holding Temperature <br /> - Method x � e _ gm P-.* <br /> f" n <br /> Screening Method ' <br /> Tracking Sheet (y/n) g; <br /> IF <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 bentonitelt - <br /> * Depth to waterBags sand/gravel <br /> Mix Ratios _ _ - Filter Pack type/size- <br /> installation <br /> ype/sizeInstallation Method ti Surge Block: -,(y/ n ) <br /> Quantity Installed <br /> Discussed with geologist: - (y/ n ) ' <br /> j Type of method <br /> 5 f <br /> EH 29 29 <br />