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MIPTORING WELL INSTALLATION REPOni• <br /> Date: <br /> �'� '0)< CONS <br /> ` Total Depthgth D (to) <br /> Premise Address: / Screen Len (from) (to)� <br /> Filter Pack (from) (to)� <br /> Well No.: // Bentonite (from) (to) <br /> Grout (from) <br /> Inspector: '" Drilling rig type <br /> �0 5 Auger O.D. I.D.�— <br /> Permit No. Completion - Stove pipe/chnstie box (circle one) <br /> Drilling Company: <br /> Z casing <br /> Driller: ' &6 t height <br /> Consultant <br /> Ii/VS P T <br /> —2s moii i _/� � w a-os- '!-BOX <br /> Geologist /✓ /80VEGROUND <br /> COf 9LETION P1E710N <br /> S(,pL CYOUnd$lAtY9 <br /> SPECIALPERMIT INFO. –9grout <br /> T. <br /> Distance to sewer line (. ft. <br /> Domestic well on site - (y(D <br /> If yes, location and distance - Jr0 it• __ <br /> I = c <br /> slotted =_ $` <br /> SAMPLING swtion __ <br /> do = gnvd pe'dc <br /> Holding TemperaiWe <br /> Method <br /> Screening Method <br /> Tracking Sheet - y n ) -70 ft = n <br /> SPOILS <br /> MATERIALS/DEV ELOPMENT <br /> Storage Method Z,i e_ ( .16 <br /> Contamination Noted - (y .t ti H Sym Casing type � fL, <br /> Storage Location— BlarlL�� fr. Screen_ <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> J� Bags sand/gravel <br /> Depth to water / �(, ! Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/ n) <br /> Installation Method Discussed with geologist: - (y/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />