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MONITORING WELL IWqfHnk-RON REPOwoK <br /> Date: O CONSTRU ON <br /> Premise Address. <br /> G' Total D pth <br /> // Scre Length (from) (to) <br /> Well No.: �I � 3 ! 0 l� ` �� Filter ack (from) (to) <br /> Ben nite (from) (to) <br /> Inspector: Gr ut (from) (to) <br /> D ling rig type <br /> Permit No. uger O.D. I•D• <br /> ompletion - Stove pipe/christiebox (circle one) <br /> Drilling Company:. ' wo'i <br /> Driller: —T-^ casing <br /> ♦ height <br /> Consultant t <br /> WT <br /> Geologist <br /> ABOVE-GROUND CHRI WX <br /> OOMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewerline <br /> grout <br /> Domestic well on site!tan <br /> y ,If yes, location and dice - ft. <br /> ft. <br /> SAMPLING /V f 4- _ d <br /> alattad C <br /> Holding Temperature vr. <br /> Method ` _ �`�! <br /> Screening Method = <br /> Tracking Sheet - (y/ n ) IF <br /> SPOILS /� <br /> Storage Method 3MATERIALS/DEVELOPMENT <br /> Contamination Noted - y/ n P�C/ <br /> tf 1/ <br /> Storage Location �J1�- S _ _ Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water ti Z-d Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method _ Surge Block: - (y/ n ) <br /> Quantity Installed [/�l.<-t'z� _ Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />