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—JNITORING WELL INSTALLATION REPO, <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (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 /> Driller: casing <br /> F7Consultant <br /> � he±qht -i- <br /> Geologist _ r <br /> ABOVE-GROUND CF RIM-BOX <br /> COAPLETION COMPLETICN <br /> SPECIAL PERMIT INFO. Ground Surtan <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> ft. <br /> If yes, location and distance - <br /> tt tt. <br /> a <br /> _ m <br /> SAMPLING donai <br /> sarien <br /> Holding Temperature <br /> Method = <br /> Qnf <br /> Screening Method <br /> Tracking Shcet - (y/ n ) `;' <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) <br /> Storage Location Casing type <br /> Blank ft. Screen h. <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 />