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k <br /> �JNITORING WELL INSTALLATION REPO,--/ <br /> Date• h/ <br /> CONSTRUCTION <br /> r� �/ p <br /> Premise Ad ess• O` /v, Total Depth <br /> Screen Length (from) (to)- <br /> Well No.: Filter Pack (from) (to) <br /> c <br /> Bentonite (froth) (to) <br /> Inspector. cam°m . Grout (from) (to)- <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist • AE&E4RCUND <br /> COMPLETION �it5'1Y-80X <br /> COMPLEnON <br /> SPECIAL PERMIT INFO. Ground Strtaca <br /> Distance to sewer line 4rout <br /> Domestic well on site - (y/ n} � - '-ft. <br /> If yes, location and distance - M <br /> K. <br /> .M. <br /> V� f <br /> SAMPLING <br /> sacion <br /> Holding Temperature_ lJ " — pacx <br /> Method_ 4/11— <br /> Screening Method ' = <br /> Tracking Sheet (y/ n } UZ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) <br /> Storage Location Casing type <br /> Blank ft. Screen fL <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 />