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'-wAQNITORING WEIL INSTALLATION REPO-,) <br /> Date: <br /> 3 �?3 U N <br /> Premise Address: S'4j- j6&jxo 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/chrisde box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist <br /> AI E-GRG' ND SIM-BOX <br /> COMPLET*N COMPLETON <br /> SPECIAL PERMIT TNFO. or d <br /> Distance to sewer line <br /> Domestic well on site - (y/n) �_ft. <br /> If yes, location and distance- {L <br /> Jk <br /> la <br /> t- <br /> ' <br /> SSWPUNG slored <br /> Holding Temperature w = gMVW past <br /> Method <br /> Screening Method <br /> Tracking Sheet - {y/n) <br /> n <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMFj�a <br /> Contamination Noted - (y/n} <br /> Storage Location Casing type <br /> Blank ft. 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 19 <br />