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---- ----� <br /> N40NITORING WELL INSTALLATION REP,OIRT <br /> Date: / 0 �S CONSTRUCTION <br /> Premise Address: 0 0 Total Depth l <br /> Screen Length (from) _ (to) _ <br /> Well No.: ` <br /> Filter Pack (from) 1 3 (to) 4- <br /> Bentonite (from) ib (to) 13 <br /> Inspector: Grout (from (to) <br /> 1 r Drilling rig type ��- <br /> Permit No. Auger O.D. <br /> I .. 11 d C� Completion - Stove pipe/ e o (circle one) <br /> Drilling Company: W 0 <br /> Driller: LILL <br /> casing <br /> height <br /> Consultant - �n � <br /> Geologist rvA -4-A-1. ._ <br /> ABOVE-GROUND <br /> COMLETION C- STY$0X <br /> SPECIAL PERMIT INFO. p,rourd Sexy COMPLETION <br /> Distance to sewer line grout <br /> Domestic well on site - ( y/ n) <br /> If yes, location and distance - <br /> �ft. ft. <br /> — e <br /> SAMPLING <br /> slonad <br /> ticjon1 F — <br /> Holding Temperature <br /> Method __ grays'Pack <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - y n ) „ n ` / C— <br /> Storage Location Casing type j V <br /> Blank ft. Screen <br /> Slot size r ?/ <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 /> �J , C. <br />