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MONITORING WELL INSTALLATION ORT <br />Date: <br />Premise Address: S132, (We <br />Well No.: -1/ 3/ <br />Inspector: A/ r%44"I <br />Permit No. <br />Dpilia415—ny: - A6( a <br />CONSTRUCTION <br />Total Depth <br />Screen Length (from) (to) <br />Filter Pack (from) (to) <br />Bentonite (from) (to) <br />Grout (from) (to) <br />Drilling rig type <br />Auger 0.D. I.D. <br />Completion - Stove pipe/christie box (circle one) <br />4frtt /2,t, d AA <br />Driller: casing <br />height <br /> <br />Consultant <br /> <br />Geologist <br /> <br />ABOVE-GROUND <br />CO MP LET/0 N <br />SPECIAL PERMIT INFO. <br /> <br />CHRISTY-BOX • <br />COMPLETION <br /> <br />Ground Suriace <br /> <br />Distance to sewer line <br /> <br />Domestic well on site - ( y / n) <br />If yes, location and distance - <br /> <br />SAMPLING <br /> <br />Holding Temppratur,e <br />Method V/24 v-7777 <br />Screening Method <br />Tracking Sheet - ) <br /> <br />SPOILS <br /> <br />Storage Method <br />Contamination Noted - ( y / n) <br />Storage Location <br /> <br />MATERIALS/DEVELOPMENT <br /> <br />Casing type <br /> <br />Blank ft. Screen <br /> <br />GROUTING <br />Depth to water <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />EH 29 29 <br />Slot size <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />Surge Block: - ( y / n ) <br />Discussed with geologist: - ( y / n) <br />Type of method