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"AONITORING WELL INSTALLATION REP <br /> coNSTRUCCION <br /> Date. � � ! <br /> C1[7 <br /> !remise Address: Total Depth_ Screen Length (from) (to)� <br /> Well No.: Filter Pack (from) (to)_,�.,� <br /> [ I Bentonite (from) (to) <br /> Inspector r Grout (from) (to)_�� <br /> Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company. <br /> casing <br /> Driller: height <br /> Consultant1W, <br /> C'21 rV <br /> GeologistABpyE.GapUNn <br /> OOhpLET1DN CiiFi�.STY-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. OrocArd Surisco <br /> IFS <br /> Distance to sewer line <br /> Domestic well on site - {y/n ) f. <br /> If yes, location and distance - ft. <br /> �.it. <br /> ;r.h • <br /> SAMP NG •I° �` <br /> aac�on <br /> Holding Temperature V- — <br /> Method . <br /> Screening Method <br /> Tracking Sheet - (y/ n) <br /> ..�n. it. <br /> SPOILS <br /> Storage MedodMATERIALS EVELOPMENT <br /> Contamip Noted - (y/n } <br /> Storage Location Casing type <br /> Blank_ft. Screen K. <br /> Slot size <br /> GROUTING Bags cement <br /> t ► Buckets bentonite <br /> Depth to water ��Q f 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 />