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„,,,MoNITORING WELL INSTALLATION PX ,!XT <br /> CONSTRUCTION r <br /> Date: <br /> :i�� Total Depth (to) a <br /> Premise Address: Screen Length Chow) <br /> Filter Pack (from) a (to)_ <br /> Well No.: (to) <br /> . Bentonite {from} <br /> Grout (from) <br /> Inspector. -(,P/rig type -�/ °'"'sem'” <br /> Auger O.D. I D _ I.D. <br /> Permit No. Completion -Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller. height <br /> Consultant _ T <br /> Geologist CA ABOVE-GRCLMO ?' <br /> COMPLETION Ci�15TY-80X <br /> COMPLmcN <br /> SPECIAL PERMIT INFO. around Sudwe <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y n) it. <br /> If yes, location and distant - n- <br /> 0 <br /> SAMPLING ilott� _ c <br /> SOCICn _ <br /> Holding Temperature. <br /> �. r grav9l Fadt <br /> Method <br /> Screening Method V 10. _ <br /> Tracking Sheet n) <br /> — n <br /> SPOILS �} <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n <br /> Storage Location Casing e <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water_ � � Bags sand/gravel 7 TA <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 />