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MONITORING WELL I REPORT <br /> Date: Se AY��// CONSTRUCTION <br /> Premise Address: ��/' /�* ��r!w Total Depth <br /> Well No.: Screen Length (fr ) (to) <br /> Filter Pack (from (to) <br /> Inspector: Bentonite (from) (to) <br /> Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: <br /> Completion - Stove pipe/christie box (circle <br /> Driller: <br /> casing <br /> o L ' <br /> Consultantheight� /�7�1(�-L� <br /> veetagis� /�D�C.fGA Z' <br /> wVE-GROUND T <br /> NFLETION CHRIM-BOX <br /> SPECIAL PERMIT INFO COMPLEMN <br /> Ground Surface <br /> Distance to sewer line Gr <br /> Domestic well on site - (y/n ) <br /> If yes, location and distance - ft <br /> ft h. <br /> N <br /> O <br /> SAMPLING o <br /> tlo"ad — c <br /> Holding Temperature L°r'O 2 <br /> Method = P <br /> Screening Method <br /> Tracking Sheet - (y/n ) <br /> SPOILS <br /> Storage Method <br /> Contamination Noted - (Y/nMATERIALS/DEVELOPMENT <br /> ) <br /> Storage Location <br /> Casing type_a- <br /> Blank ft. Screen ft. <br /> GROUTING Slot size_ <br /> Bags cement <br /> Buckets bentonit <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ ) <br /> Quantity Installed <br /> Discussed with geol 'st - (y/ n ) <br /> EH 29 29 Type of method <br />