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10NITORING WELL INS14mREPMi i <br /> Date :-V//V/)0 L! CONSTRUCTION <br /> Premise Address: 7 Total Depth <br /> M� �- p Screen Length (from) (to) <br /> Well No. : �/ Filter Pac (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout om) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> /f&/-& / Completion - Stove e/chtistie box (circle one) <br /> DfHf mg Company: <br /> casing <br /> height <br /> Consultant G�iZ <br /> Geologist T <br /> ABOVE-GROUND <br /> COMPLETION CHRISTI'-BOX <br /> SPECIAL PERMIT INFO. GroundSurf=* COMPLETION <br /> Distance to sewer line Grp <br /> Domestic well on site - ( y / n ) I <br /> If yes, location and distance - ♦ n <br /> n. <br /> n. <br /> SAMPLING = <br /> _ c <br /> f� LYC�O <br /> Holding Temperature <br /> Method Vd/4l = 9`aw Pack <br /> Screening Method <br /> Tracking Sheet - 7 / n ) _ <br /> SPOILS <br /> Storage Method MA RIALS EVELOPMENT <br /> Contamination Noted - ( y / n ) �u w <br /> Storage Location Casing e <br /> Blank ft. Screen fr. <br /> Slot size <br /> GROUTING Bags cemen <br /> A S Buckets bent 'te <br /> Depth to water Bags sand/gra I <br /> Mix Ratios Filter Pack type ize <br /> Installation Method Surge Block: - ( n ) <br /> Quantity Installed Discussed with ge o 'st: - ( y / n ) <br /> Type of method <br /> EH 29 29 <br />