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MONITORING WELL INSTALLATION REP-e-T <br /> UCTION <br /> Date <br /> CONSTLt <br /> ?remise Address: <br /> Total Depth tAAA 0— , 2 / <br /> Screen Length (from) (to) <br /> Well No.: n J Filter Pack (fr m) (to) <br /> ,Q Bentonite ( om) (to) <br /> Inspector. "^" Grout om) (to) <br /> Drilling rig e <br /> Auger O.D. I.O. <br /> Permit No. Completion Stove pipe/cisristie box (circle one) <br /> Drilling Company <br /> cas izg <br /> Driller 7 height <br /> ♦ 7 � <br /> Consultan <br /> Geologist 1.Q•^=� AZBC —ROUND <br /> =h?!�C;CN Cl�AJS�`:'cOX <br /> COMPL=i cN <br /> SPECIAL PERMIT INFO. Ground Sufi <br /> K ' <br /> 701t <br /> Distance to sewer line <br /> Domestic well on site - ( y/ n ) - <br /> If yes, location and distance - <br /> - = a <br /> ud <br /> SAMPLINGtbc <br /> wccn <br /> Holding Temperature " <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) '` _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) Casing type .[.0 1,..� — <br /> Storage Location Blank Screen fL <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water 6 Bags sand/gravel <br /> Mix Ratios Filter Pack typesize <br /> Installation Method Surge Block- - (y/ n ) <br /> Quantity Installed Discussed with geologist: - C y <br /> Type of method <br /> EH 29 29 <br />