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MONITORING WELL INSTALLATION RESORT <br /> Date: /�d CONSTRUCTION <br /> Premise Address: ��yDw `�'�^"`�""'�- 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/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant_("�t,�,o( lJt-O <br /> Geeegist �� .� T <br /> ABOVE-GROUND <br /> COM?LET{ON COMPLETION CTON <br /> ETICN <br /> SPECIAL PERMIT INFO. Ground Suriaoa .� <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) ft <br /> If yes, location and distance - <br /> ft ft. <br /> }: O <br /> C <br /> SAMPLING _ <br /> donvd c <br /> Bacton <br /> Holding Temperature _ P <br /> ack <br /> Method _ <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 /> ✓ J G '3 Buckets bentonite <br /> Depth to water S(.r" 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 />