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� IMONITORING WELL INSTALLATION R 1RT <br /> Date:_ fig CONSTRUCTION <br /> Premise Address: I, 6 Lk�� t� L ��'�` Total Depth <br /> Well No. ;. � rA i Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector - { Ff e/t Grout <br /> (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/c •stie box (circle one) <br /> Drilling• Company: <br /> Driller: cas in <br /> heig t <br /> Consultant .�� <br /> Geologist <br /> ABOVE-GROUND <br /> COMPLETION CHRITN-BOX <br /> SPECIAL PERMIT INFO. COMPLETION <br /> Cimund Satiate <br /> Distance to sewer line grout <br /> Domestic well on site - ( y / n ) l <br /> If yes, location and distance - <br /> Ma <br /> r.; <br /> SAMPLING — o <br /> slotted = c <br /> Holding Temperature Li — <br /> Method ✓e ,d:f VA PaCR <br /> Screening Method = <br /> Tracking Sheet / n ) <br /> SPOILS ft <br /> Storage Method T�aa MATERIALS/DEVELOPMENT <br /> Contamination Noted - 0/ n ) <br /> Storage Location Casing type <br /> Blank Screen ft, <br /> Slot size <br /> GROUTING _ Bags cement <br /> 73 Buckets bentoni <br /> Depth to water Bags sand/gra el <br /> Mix Ratios Filter Pack type/size <br /> Installation Method _ Surge Block: - ( y / n ) <br /> Quantity Installed Discussed with geologist; - ( y / n ) <br /> EH 29 29 Type of method <br />