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PMONITORING WELL INSTALLATION REAr <br /> Date: '` K / CONSTRUCTION <br /> Premise Address: 517k W, CN &'Vy' N Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> I1 �^�� Bentonite (from) (to) <br /> Inspector: lYC/ Grout (from)—(to)— <br /> Drilling <br /> from) (to)Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: Iffcasing <br /> height <br /> Consultant TRY V –� <br /> Geologist ABOVE-GROUND <br /> OCk PL.ETION CHRISTY 80X <br /> COMPLETION <br /> SPECIAL PERMIT I �'� SuAx� �-- <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y/n) n. <br /> If yes, location and distance - ft. <br /> n. <br /> T <br /> •� 0 <br /> O <br /> T \ = O <br /> 6 ,w, Si J6 slotted = <br /> SAMPLING sacdon = <br /> e — <br /> Holding Temperature gr pack <br /> Method 'V <br /> Screening Method <br /> Tracking Sheet - (Y/ n) <br /> n. LZ <br /> = n. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) <br /> Storage Location Casing type <br /> Blank fr. Screen_ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br />