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„.,jNITORING WELL INSTALLA'T'ION REPO'-04 <br /> Date: y l% CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) <br /> Well No.: f Filter Pack (from), (to)�._ <br /> Bentonite (from) (to)— <br /> Inspector. <br /> to) _Inspector. Grout (from)_ (to)— <br /> Drilling rig type <br /> Permit No. 7 Auger O.D. I.D• <br /> Completion -Stove pipe/christie box (circle one) <br /> Drilling Company '� ann <br /> Driller: �� o casing <br /> T height <br /> Consultant �(047 t J <br /> Geologist ABOVE-GROUND <br /> COMPL,Ei'iON CHRS.SIY-BOX <br /> CCMPLU” <br /> SPECIAL PERMIT INF9, MCI"$Wfwo <br /> Distance to sewer line <br /> Domestic well on site - {y/n) <br /> If yes, location and distance - ft. <br /> SAMPLING sbttsd "y <br /> 0 d &*don <br /> Holding Temperature gmvo Pads <br /> Method � - � <br /> Y� <br /> Screening Method = <br /> Tracking Sheet - {y/n) <br /> '=' = fL <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Note {y/WY <br /> Storage Location ming type <br /> Blank--------& Screen ft• <br /> Slot size <br /> GROUI7NG_ Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <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 />