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MONITORING WELL INSTALLATION, ORT <br /> Date: IL'1�5 CONSTRUCTION <br /> Premise Address: / d 'w oe� Total Depth I S <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> /h l 5 0 g s Drilling rig type <br /> Permit No. V U l Auger O.D. I.D. <br /> Completion - Stove pipe/christie bog (circle one) <br /> Drilling Company: (/ <br /> Driller: <br /> casing <br /> height <br /> Consultant M i IRV <br /> ► <br /> IJ <br /> Geologist - LKJ✓`C� <br /> ABOVE-GROUND <br /> COMPL._�'T10N CtiFilSfY-80X <br /> COMPL E710N <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - fL <br /> is O <br /> — C <br /> SAMPLING n <br /> aKson = <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n) <br /> !L — fL <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft Screen ft <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water N Bags sand/gravel <br /> Mix Ratios Filter Pack typesize <br /> Installation Method Surge Block. - (y/ n ) <br /> Quantity Installed Discussed with geologist. - (y/ n) <br /> Type of method <br /> EH 29 29 <br />