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ONITORING WELL INSTALLATION REPO <br /> Date:_ CONSTRUCTION <br /> Premise Address: Total Depth IN <br /> Screen Length (from) jq? (to) i co <br /> Well No.: Filter Pack (from) it D (to) r 7 <br /> n ( C 9 Bentonite (from) ?`3 (to) <br /> Inspector: ���� f . Grout (from) i (to)ac., <br /> Drilling rig type r a. <br /> Permit No. 00L / Auger O.D. 13 /y 1.DN <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: � casing��' height <br /> Consultant ��' �� –�^ <br /> Geologist <br /> T <br /> ABOVE•GRCUND CF4i15TY BCX <br /> COMPLrR10N COMPLETiCN <br /> SPECIAL PERMIT INFO. Ground Suixv <br /> Distance to sewer line U ' grout /UOt C <br /> Domestic well on site (7) /7/ <br /> If yes, location and distance - �� <br /> ,4L'C ft. <br /> — m <br /> SAMPLING /Ljrl <br /> a <br /> doNad � <br /> soc'cn = <br /> Holding Temperature = gnvw F <br /> Method = <br /> ack <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted . (y/ n ) <br /> Storage Location Casing type <br /> Blank loo ft. Screen i t, ft. <br /> Slot size • b <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water 1-� Bags sand/gravel 14 _ <br /> Mix Ratios vv LQ_ Q^ l Filter Packtype/ ' e <br /> Installation Method ti. Surge Block: - <br /> yi n ) <br /> Quantity Installed % /0 w_ Discussed with eologisr: • / n ) <br /> Type of method <br /> EH 29 29 <br />