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MONITORING WELL INSTALLATION REPCFAT <br /> Dater CONSTRUCTION <br /> Premise Address: 1 �y L �" Q Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> l /� Bentonite (from) (to) <br /> Inspector. 7�/(\ Groue (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Complet on - Stove pipe/cltr stie box (circle one) <br /> Drilling Company. L i S E cG�C <br /> Driller•. I casing <br /> height <br /> Consultant 'y + <br /> Geologist 'U C) <br /> ABOVE-GRCOND <br /> CXl A r'LETION ChAZ7Y•BOX <br /> SPECIAL PERMIT INFO. Ground <br /> Cc M? =TICN g,s{xy <br /> Distance to sewer line Qrat <br /> Domestic well on site - (y/ n ) II <br /> If yes, location and distance - <br /> • ft. <br /> h. <br /> SAMPLING <br /> ilonAi � <br /> soc cn — J� <br /> Holding Temperature <br /> Method <br /> = — <br /> Screening Method <br /> Tracking Sheet - (y/ n ) _ <br /> ft. = — ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) <br /> Storage Location Casing type <br /> Blank fr. Screen h• <br /> Slot size <br /> GROLMNG Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravcl <br /> Mix Rados Filter Pack type/size <br /> dFtstalladon Method Surge Block: - (y/ n ) <br /> Quantity installed Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29. . <br />