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MONITORING WELL INSTALLATION Iv. ORT <br /> Date: 14i /cw CONSTRUCTION <br /> Premise Address6 <br /> Total Depth <br /> !` Screen Length (from) (to) <br /> Well No.: At If/7 of j,/ 7 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/christie box (circle one) <br /> Drilling Com any: <br /> Driller: casing �---- <br /> height <br /> ConsultantL SI / T <br /> rnAH <br /> Geologist t t'R D( •� T <br /> ABOVE-GROUND <br /> COMPLETION CtiFU57Y-80X <br /> C hC�hAPLETION <br /> SPECIAL PERMIT INFO. Ground Surlwe <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - ft. <br /> ft. <br /> SAMPLING slotted ._ c <br /> axion <br /> Holding Temperature P <br /> ack <br /> Method <br /> Screening Method A _ <br /> Tracking Sheet - (y/n) — <br /> tt. = ft. <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 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 />