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VONITORING WELL INSTALLATION REPO <br /> Date: ` { 3 �' �'� CONSTRUCTION <br /> I <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> - Well NO.: Filter Pack (from) I (to) <br /> Bentonite (from) to <br /> Inspector: Grout (fro;n) (to) a crU <br /> ��� _Drilling rig type <br /> Permit No. _ l Auger O.D. I.D. o <br /> Completion - Stove pip e o (circle one) <br /> Drilling Company:— <br /> Driller: j\ casing <br /> n height <br /> Consultant r P <br /> Geologist .( .L1 n Gt✓CJ[/�� <br /> ABOVE-GROUND CtiSM Y-8CX <br /> 0OWIl;7ON COMALETICN <br /> SPECIAL PERMIT INFO. around Stiriaci <br /> Distance to sewer line grout <br /> Domestic well on site - (y n ! P,, ft. <br /> If yes, location and distan M <br /> .�ft. <br /> v <br /> r <br /> SAMPLING sat.'o. — c ► <br /> Holding Temperature l/V— r - Gra I <br /> ack <br /> Method ` <br /> Screening Method t7b <br /> Tracking Sheet - (y n ) <br /> SPOILS <br /> Storage Method 5S d✓ ivy MATERIALS/DEVELOPMENT <br /> Contamination Noted - {y rr <br /> Storage Location_ Casing type T V <br /> BIank. I D ft. Screen ft. ► <br /> Slot size- <br /> GROUTING <br /> izeGROUTING r Bags cement d— <br /> Buckets bentonite <br /> Depth towater ^ Bags sand/gravel <br /> Mix Ratios Filter Pack type/size L <br /> Installation Method Surge Block: - ( n <br /> Quantity Installed eo o <br /> Discussed with glst: - {y/ n} <br /> Type of method <br /> EH 29 29 <br /> Ii <br />