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*ONITORING WELL INSTALLA'T`ION REPO <br /> Date: hi h 6 CONSTRUCTION <br /> Premise Address:U� Total Depth <br /> Screen Length (from) (to) . . <br /> Well No.: Filter Pack (from) (to)� <br /> Bentonite (from) (to) <br /> Inspector. Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height —ev <br /> Consultant '4 <br /> Geologist -- <br /> ABOVE-GROUND CHfiIM-box <br /> COMPLETION COMPL EMON <br /> SPECIAL PERMIT INFO. G=rd Sumacs <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - (y/n ) �► ft. <br /> If yes, location and distance - �+ <br /> V• O <br /> SAMPLING = o <br /> slar.4.•! ::: � <br /> sacicn " — <br /> HoIding Temperature <br /> Method =7 — 9M Pack <br /> Screening Method <br /> Tracking Sheet - (y/ n ) — <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios _ _ j 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 />