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\.,JNITORING WELL INSTALLATION REPC,,.# <br /> Date: 3l CONSTRUCTION <br /> Premise Address: — ! Total Depth <br /> Screen Length (from) 6:) (to) <br /> Well No.: 4> w Filter Pack (from) —(to)--3_ - <br /> Benconite (from) 3 (to) / <br /> Inspector. � Jc Grout (from) (to) <br /> Drilling rig type- S�E- <br /> Permit No. Auger O.D. A;—" I.D. /O <br /> Drilling Company: d' a.`�-� Completion - Stove pipe/ehrt (circle one) <br /> � C <br /> Driller:_- ___ T <br /> casing <br /> T height <br /> Consultant +� �7 <br /> 7 <br /> Geologist__ 1 �-- <br /> AsovE-CRCU D CHRW r-Sox <br /> OOMPL.EMN ca41Pl�mCN <br /> SPECIAL PERMIT INFO. ► v�" "� Ground Suriaci <br /> grout <br /> Distance to sewer line l <br /> Domestic well on site - (y/ n) tt- <br /> If yes, location and distance - <br /> C <br /> SAMPLING = Q <br /> sacicn s <br /> Holding Temperature <br /> Method _ �`"YW F <br /> ack <br /> Screening Method = `� <br /> Tracking Sheet - {y/ n ) <br /> tt. <br /> SPOILS <br /> Storage Method S MATERIALS/DEVELOPMENT <br /> Contamination Noted - (g' n ) <br /> Storage Location Casing type '4 �/ �1� <br /> Blank Cl�;— . h. Screen l5 ft. <br /> Slot sizei7-2 t� <br /> GROLMNG 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 />