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MONITORING WELL INSTALLATION REr T <br /> I <br /> aG, <br /> Date:AI , � h CONSTRUCTION// <br /> Premise Address ; J (J✓LIL�t Lrµe KQDFIFF Total Depth b r <br /> Screen Length (from) (to) <br /> Well No. ; AW 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 /> Drilling Company: Completion . Stove pipe/cluistie box (circle one) <br /> Driller: casing <br /> �g <br /> Consult===llie (n, i? A height� � <br /> Ge f /ti< � <br /> ABOVE-GROUND <br /> COWLEMN CHA MOBOX <br /> SPECIAL PERMIT INFO. ® 6raurd gutxy <br /> COMPLETION <br /> Distance to sewer line prcut <br /> Domestic well on site - ( y / n ) <br /> If yes, location and distance - no <br /> • tt tt. <br /> IF <br /> FF <br /> oFoo <br /> SAMPLING sIot:Ai — c <br /> sucticn <br /> Holding Temperature <br /> MethodIF <br /> Screening Method _ = <br /> Tracking Sheet - ( y / n ) — <br /> = tte <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y / n ) <br /> Storage Location Casing type <br /> Blank ft. Screen fr. <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: - ( y / n ) <br /> Quantity Installed Discussed with geologist: - ( y / n ) <br /> EH 29 29 Type of method <br />