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_�- <br /> MONITORING WELL INSTALLATION REPO. <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonire (from) (to) <br /> Inspector. Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: I7m6tv height <br /> Consultant � <br /> Geologist ABOVE-GRCUND c4-iR*-ry80X ' <br /> COhvLETION CGY 1PLE71CN <br /> Ground Sulact <br /> SPECIAL PERMIT INFO. <br /> prat <br /> Distance to sewer line tt. <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - —ft. <br /> V' r <br /> _ O <br /> 1106d C <br /> SAMPLING SOClcn <br /> Holding Temperature <br /> Method — <br /> screening Method — <br /> Tracking Sheet - (y/ n) = ' <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) Casing type <br /> Storage Location Blank ft Screen —� <br /> Slot size <br /> GROIfRNG - - Bags cement <br /> Buckets bentonite <br /> Depth to water Filter <br /> sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> M <br /> d,pix Ration Method Surge Block: - ( y/n ) <br /> Quantity Installed Discussed with geologist:. - (y/ n) <br /> Type of mctitod <br /> EH 29 29 <br />