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MONITORING WELL INSTALLATION 1, ORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Well No.: <br /> Screen Length (from)' (to) <br /> Filter Pack <br /> . (from) (to) <br /> Bentonite' (from) (to) <br /> Inspector: Grout (from) '(to) <br /> Drilling rig type ' <br /> Permit No.- Auger O.D. I.D. <br /> Drilling Company: Completion- Stove pipe/chnstie box (circle one) <br /> Driller: <br /> casing <br /> height <br /> Consultant ' <br /> Geologist <br /> ABOVE-GROUND <br /> COh 'LET}ON C4-iRXTY-50X <br /> SPECIAL PERMIT INFO. COMPLET]ON <br /> C-ground Surfxa <br /> Distance to sewer line Grout <br /> r�,;.,o�.; , ,en <br /> If yes, location and distance - tt, <br /> ft. tt. <br /> — m _ <br /> SAMPLING = <br /> ' ilottad - — <br /> " <br /> Holding Temperature <br /> Method grzval Pack <br /> Screening Method — <br /> Tracking Sheet - (y/n) <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 bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method __, Surge_Block: <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> EH 29 29 <br /> Type of method <br />