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07 Date: I/ CONSTRUCTION <br />Inspector: (4/k <br />Depth to water <br />MiX Ratios <br />MONITORING 'WELL INSTALLATION RFP013.T <br />Premise Address: Z072- 6?-)tigi°7-) <br />Well No.:. 41V /1 <br />Permit No. <br />Total Depth <br /> <br />Screen Length (from) (to) <br />Filter Pack (from) (to) <br />Bentonite (from) (to) <br />. Grout (from) (co) <br />..Drilling rig type <br />Auger 0.D. I.D. <br />Drilling Company: <br />DriBer <br />Consultant <br />Geologist <br />SPECIAL PERMIT INFO. <br />Distance to sewer line <br />Domestic well on site ( y / n ) <br />If yes, location and distance. <br />SAMPLING <br />Holding Temperature <br />Method <br />Screening Method <br />Tracking Sheet - ( y/ n ) <br />SPOILS • <br />Storage Method <br />Contamination Noted- ( y / n) <br />Storage LOcation <br />GROUTING <br />installation Method <br />Quantity Installed <br />EH 29 29. • <br />Completion - Stove pipe/christie box (circle one) <br />casing. <br />height <br />ABOVE-CR CUND <br />COMPLETION Cl-nISTY-BOX * <br />COMPt-t-TION <br />Geound Sula4-1 <br />MATERIALS/DEVELOPMENT <br />/cy <br />Surge Block:- ) <br />Discussed withologist: - <br />Type of method cns <br />Bags cement d-- <br />Buckets bentonite S <br />Bags sand/gravel #3. <br />Filter Pack type 'zell -3 <br />Casing typ <br />Blank <br />Slot size • 0 '0-0 <br />Screen410 ft.