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MONITORING WELL INSTALLATION R U--e-T <br /> Date: ! CONSTRUCTION <br /> Premise Address: � Total Depth <br /> Seq-eea.Length_(from) (to) <br /> Well No.: <br /> l� / — lh hJ J I) Filter Pack (from) (to) <br /> W <br /> Bentonite (frgm) Cto) <br /> Inspector: Grout (frost) Cto) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. . <br /> Completion -Stove pige/chtisde box (circle one) <br /> Drilling Company: , <br /> Driller. cas Ing <br /> Q he-ight <br /> Consultant <br /> Geologist <br /> ABCVE-GROUND CHRzrY-3ox <br /> SPECIAL PERMIT INFO. Cvaxd Surface <br /> Distance to sewer line <br /> Domestic well on site - ( y <br /> If yes, location and distance - tL <br /> a <br /> -. - is � • - <br /> O <br /> SA11+[PL ING <br /> Holding Temp tup `fes L - 71"1 pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - VII/ a ) <br /> IML. �' = tL <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - n) <br /> Storage Location Casing type <br /> Blank ft. Screen � <br /> Slot size <br /> GROUITNG Bags cement <br /> Buckets bentonite <br /> Depthter Y � I� low Bags sand/ el_ <br /> Mix Ratios / Filter Pack type/size <br /> Installation Method Surge Block- - C y/ n ) <br /> Quantity Installed Discussed with geologist: - C y/ n) <br /> Type of merhod <br /> EH 29 29 <br /> r . <br />