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MONITORING WELL INSTALLATION REi _T <br /> Date: S I /oL CONSTRUCTION <br /> Premise Address: Z 0 Total Depth L <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> /'L / Bentonite (from) (to) <br /> / <br /> Inspector: L4:::C - - Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> // Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant J_.T7F <br /> Geologist L�`��c •- <br /> ABOVE-GROUND <br /> COMPLETION Ct�iRISTY-$OX <br /> COMPLETICN <br /> SPECIAL PERMIT INFO. Ground Surfac4 <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> ft. <br /> If yes, location and distance - <br /> ft. <br /> ft. <br /> m <br /> a <br /> _= c <br /> SAMPLING slotted <br /> seclon <br /> Y <br /> Holding Temperature gravW pack <br /> Method — <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen fr. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/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 />