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AONITORING WELL INSTALLATION REF T <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to)_� <br /> Well No.: 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 /> Completion - Stove pipe/cliristie box (circle one) <br /> Drilling Company: �� <br /> Driller: casing <br /> height <br /> 11 �nConsultant TAA'J=l <br /> Geologist 5La-.- - <br /> ABVIE-GACUND <br /> CUf�L.cTfOFd CHRZ Y-aOX <br /> COMPL E7nCN <br /> SPECIAL PERMIT INFO. Ground Sulacs a.�® <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - ( y/ n ) ft. <br /> If yes, location and distance - <br /> ft. <br /> _ a <br /> = m <br /> = o <br /> c <br /> SAMPLING <br /> tocicn <br /> Holding Tempera r �(, <br /> Method �-�Pack <br /> Screening Method :r <br /> Tracking Sheet n ) _ <br /> SPOILS <br /> Storage Method MAI-ERIALS/DEVELOPMENT <br /> Contamination Noted - ( n ) <br /> Storage Location dbh Ile ato 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: - ( y/ n ) <br /> Quantity Installed _ Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />