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MONITORING WELL INSTALLATION RE1"AT <br /> Date: // o?�/� 25- 10,7 CONSTRUCTION <br /> Premise Address: p" Total Depth__��� <br /> p Screen Length (from) (to) <br /> Well No.: y PA6� Filter Pack (from) (to) <br /> / ' Bentonite (from) (to) <br /> Inspector: } A_'P� Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> r Completion- Stove pipe/christie box (circle one) <br /> Drilling Company:/kc <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist <br /> Ag80 -GROUND <br /> COMPLETION C <br /> SPECIAL PERMIT INFO. Ground Surface COOMPLMPLETIOMNN <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n ) <br /> If yes, location and distance - ft. <br /> ft. <br /> n — m <br /> _ <br /> SAMPLING slotted = g <br /> secdon <br /> Holding T mperaVW <br /> ture <br /> Method a4 . ItIN"l `C _ V& ` <br /> Screening Me od — <br /> Tracking Sheet - (y/n) 4 <br /> 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 /> b - S Buckets bentoni <br /> Depth to water Bags sand/grav 1 <br /> Mix Ratios N-+.ltll Filter Pack tyr /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 />