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-UNITORING WELL INSTALLATION REPGJ <br /> , <br /> Date: / �L 7�� �4 CONSTRUCTION ti <br /> Premise Address:__/f1 �D W Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from)-(W) <br /> Inspector. Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> / �// height <br /> Consultant CGCG <br /> Geologist <br /> ABOVE-GRCUND CH SN-BOX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surtan <br /> Distance to sewer line _ grout <br /> Domestic well on site - (y/ n) _tt. <br /> If yes, location and distance - g <br /> . n <br /> iGGGOa <br /> SAMPLING Bored — <br /> soaicn —' <br /> Holding Temperature _ gray9l pack <br /> Method 77 <br /> Screening Method <br /> Tracking Sheet - (y/ n ) ` <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted -a/ 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 type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br />