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"40NITORING WELL INSTALLATION RF-Pf011111r <br /> ` 1—Y <br /> Date: 76 _ CONSTRUCTION <br /> Premise Address: /y� w� __ f� Total Depth <br /> /rj, Screen Length (from) (to) <br /> Well Nd'. I ` �� Filter Pack (from) (to) <br /> �(�(f `p Bentonite (from) (to) <br /> Inspector: Lam"'"' `" Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> caging <br /> height <br /> Consultant <br /> Geologist _ �► <br /> ABOVE-GROUND <br /> COWL.I ION CHR*STY-BOX <br /> COMPt.ETI N <br /> SPECIAL PERMIT INFO. Ground Su fa" <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - ft• <br /> • ft• ft. <br /> — m <br /> oA d <br /> • c <br /> SAMPLING — <br /> doted <br /> tacton — <br /> HoIdmg Temperature �� = . <br /> Method �"°�Pack <br /> Screening Method '— <br /> Tracking Sheet - {y/ } <br /> n <br /> .,.,_.,..._ft. <br /> SPOILS <br /> Storage Method MATERIALS EVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack typesize <br /> Installation Method Surge BIock: - (y/ n) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />