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`/NITORING WELL INSTALLATION REPOT� <br /> Date: r r J CONSTFtUCnON <br /> Premise Address:— Total Depth— <br /> Screen <br /> Screen Length (from) Cto}Well No.: Filter Pack (from) ' (to) _ 3 <br /> Bentonite (from) 3 _ —(to) a <br /> Inspector: Grout (from) <br /> _(to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> r Completion - Stove pipe/ tie o circle one) <br /> Drilling Compan . <br /> - !��& <br /> casLnq <br /> Driller: he;ght <br /> Consultant <br /> L4 -EWT <br /> C <br /> Geologist AByE-GRO CHRM N43OX <br /> CokVL.eTiON COMPLETION <br /> SPECIAL PERMIT INFO. Clmu d ace <br /> 9r� <br /> Distance to sewer line <br /> Domestic well on site - y n <br /> If yes, location and di e - tL <br /> h � � <br /> v + <br /> jioro <br /> SAMPLING s •:� g <br /> Path <br /> Holding Temperature <br /> Method <br /> Screening Method — ' • <br /> Tracking Sheet - (y/ n) <br /> Ott. fL <br /> SPOIiS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - / r PVL- <br /> Storage <br /> U G <br /> Storage Location Casing type C — <br /> Blank 5 ft. Screen —' ft. <br /> Slot size 6 �— <br /> GROIJTING Bags cement <br /> S Buckets bentonite <br /> Bags sand/gravel. 3 <br /> Depth to water 5 <br /> Mix Ratios Filter Pack type/size G <br /> Installation Method Surge Block: - C y/ n ) <br /> Quantity Installed Discussed with geologist: - C y/ n } <br /> Type of method <br /> EH 29 29 <br />