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\ .JNITORING WELL INSTALLATION REPO.—/ <br /> Date: l / Y /f CONSTRUCTION <br /> Premise Address: �� !( Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <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: � �//1��'lr1'l,!-vt <br /> Driller: "j)JY� Cv- casing <br /> � lGt 171 height <br /> Consultant <br /> T <br /> Geologist L G/ -- <br /> ABOVE-GACUND CtWIM43OX <br /> COMPLETCN COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surfaea <br /> Distance to sewer line Omit <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - ft. <br /> tt. <br /> SAMPLING doral <br /> aoricn =_ <br /> Holding Temperature = a Pack <br /> Method _�Z7e <br /> Screening Method <br /> Tracking Sheet - (y/ n) <br /> '.x <br /> ft. <br /> SPOILS <br /> Storage Method dyI UIS d C'p MATERIALS/DEVELOPMENT <br /> Contamination Noted q y/ <br /> Storage Location___.t12 $ Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> > Buckets bentonite <br /> Depth to water ti f� 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 />