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1 <br /> MONITORING WELL INSTALLATION REP-e-T <br /> Date: ���I CONSTRUCTION R <br /> Premise Address: (Q T Z Total Depth 7S <br /> Screen Length (from) (to) <br /> Well No.: lMit. 7-, }Z Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> �k� •�� Grout (from) (to) <br /> Inspector. - <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> cas ing <br /> Driller. <br /> height <br /> Consultant pp F=1 � <br /> Geo [ �o XT➢r� I18CVE GRCUNO r <br /> Grua!E-mN comp= <br /> omp !-ICN <br /> CQMPC=TiCN <br /> SPECIAL PERMIT INFO. "' —� <br /> r <br /> n� <br /> Distance to sewer line <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - ii <br /> 73r <br /> i <br /> O <br /> SAMPLING <br /> ►aden � <br /> Holding Temperature _ —_ .T+ °�Dacx <br /> Method <br /> Screening Method <br /> Tracking Sheet • ( y/ n ) _ <br /> SPOILS N <br /> Storage Method MATER[ALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Cuing type <br /> Blank fc Screen <br /> Slot size 07_0 - <br /> GROIMNG Bags cement <br /> Buckets bentonite <br /> Depth to water�Z6 Bags sand/gravel — <br /> Filter Pack type/size <br /> Mix Ratios <br /> ISurge Block - (y/ n <br /> Installation Mechod <br /> Quantity Installed Discussed with geologist - / n) <br /> Type of method - <br /> EH 29 29 <br />