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MONITORING WELL IN RFPOIZY <br /> Date: ( /6L 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 /> P Drilling rig type <br /> Permit No. Auger O.D. IM. <br /> — <br /> completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller. —,F height <br /> Consultant <br /> Geologist ABOVE-GFICUNG CHRI 43OX <br /> COMPLETION COMPLET" <br /> PECIAL PERMIT INFO Sura <br /> grout <br /> Distance to sewer line 1 <br /> Domestic well on site- (y/n) -----�»Tt. <br /> If yes,location and distance - It. <br /> rs + <br /> •i•: d <br /> SAMPLING storm <br /> s*don = <br /> p <br /> Holding Temperature = iv W pack <br /> Method <br /> Screening Method • ' • <br /> Tracking Sheet - (y/n) <br /> §POILS <br /> Storage Method MATERIA gMM ELOPMENT <br /> Contamination Noted- {y/n} ming type <br /> Storage Location Blwjk fr. Screen ft. <br /> Slot size <br /> GR^OUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack typesize <br /> Installation Method Surge Block: - (y/n-) <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br />