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i <br /> MONI'T'ORING WELL INSTAL.L.ATION R P---,-T <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter ?ack (from) (to) <br /> Bentonite (from) (to) <br /> Grout (From) (to) <br /> inspector. Dein ng gtyPe <br /> ?ermit No. Auger O D. I•'� <br /> Completion Stove pipe/cnristie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller. � ` � height � <br /> Consultant I ' <br /> Geologist ABCV---3RC(JND <br /> C}-FiZ"!oOx <br /> cc},h?�°TzN cCMPI i ICN <br /> SPECIAL PERWT INFO. Gr=cd Sulacs <br /> ;tact <br /> Distance to sewer line <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - <br /> _ o <br /> = o <br /> SAMPLING iloctpd = a <br /> w• _� <br /> aoc:cn Hn <br /> Holding Temperature _ <br /> Method <br /> Screening Method <br /> Tracking Sheet ( y/ n ) j. <br /> SPOILS <br /> Storage Nlethod MATERIAIS/DEVELOPNIENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Steen fT- <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravei <br /> Mix Ratios Filter Pack typesize <br /> Installation Method Surge Block- - ( y/ n ) <br /> Quantity Installed Discussed with geologist - C y/ a ) <br /> Type of method <br /> EH 29 29 <br />