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JNITORING WELL INSTALLATION REP�­,,i <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/clu-istie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> FMLheight <br /> '4 + <br /> Consultant _ <br /> Geologist _ o <br /> 1�0 VE-G R CIJND ChRZTY-30X <br /> COMP LET C N CO4.40LE'TICN <br /> SPECIAL PERMIT INFO. Ground Suiacs <br /> Distance to sewer line _ prCut <br /> Domestic well on site - (y/ n) ft. <br /> if yes, location and distance - 1, <br /> _ ft. <br /> M <br /> C <br /> O <br /> SAMPLING ilor� <br /> socicn _— � <br /> Holding Temperature —' <br /> Method <br /> r <br /> Screening Method = <br /> Tracking Sheet - ( y/ n ) <br /> ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <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 Rados 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 />