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N[ONITORING WETS.INSTAL1 AmON REPOAT <br /> Date: r O <br /> Premise Address: Z14�01*1' 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 gipe/christie box (circle one) <br /> Drilling Company: <br /> Driller. casing <br /> 11M —qW–f <br /> T height <br /> Consultant 7 1,q <br /> � � p <br /> Geologist <br /> ABOVE-GACUND CHRIM43OX <br /> COWLET1ON COMPLETION <br /> SPECIAL PERMIT INFO, Gronrd Sislact <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) _ <br /> If yes, location and distance- <br /> tt. <br /> SawUriG sloned — E <br /> Holding Temperature 7J�i N <br /> Method <br /> Screening Method <br /> Tracking Sheet - {y/n) <br /> Emus <br /> Storage Method MATERiALS/DEVELOPMENT <br /> Contamination Noted - (y/n} <br /> Storage Location Casing type <br /> Blank fL Screen.& <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 />