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*aOJNITORING WELL INSTALLATION REPO <br /> Date: fitI CONSTRUCTION <br /> Premise Address:?8�y c' ` - Total Depth <br /> Screen Le Ur m) (to) <br /> Well No.: Filter Pack ( om) (to) <br /> --& <br /> om) (to) <br /> Grout (fr ) (to) <br /> Inspector: i� <br /> Drilling ri e <br /> Auger O. . I.D. <br /> Permit No. Completion - Stove pipe/ luisdebox (circle one) <br /> Drilling Company: tf� <br /> casing <br /> Driller: height <br /> Consultant <br /> GeologistG/fitoVE.GROUND <br /> COMPLETION Cn CHROTY•BOX <br /> COMPLEnCN <br /> SPECIAL PERMIT INFO. _ Ground Swi <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) _ft. <br /> If yes, location and distance - ft <br /> _ m <br /> 0 <br /> 0 <br /> r <br /> c <br /> SAMPLING donod — c <br /> saclon <br /> Holding Temerature A^ <br /> acR <br /> Method i = ��P <br /> Screening Method = <br /> Tracking Sheet - y n ) <br /> SPOILS <br /> Storage Method � MATERIALS/DEVELOPMENT <br /> Contamination Noted • n ) O al� <br /> Storage Location Casing type 2- VL �/I AAL) AN <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> 3?t 3� Buckets bentonit <br /> Depth to water Bags sand/grav <br /> Mix Ratios Filter Pack typ size <br /> Installation Method _ Surge Block: - y/ n ) <br /> Quantity Installed Discussed wi geologist: - ( y/ n ) <br /> Type of me od <br /> EH 29 29 <br /> 9 <br /> n � ao <br />