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INITORING WELL INSTALLATION 1. .ORT <br /> I <br /> 4 <br /> CONSTRUCTION <br /> Date: <br /> Total D epth <br /> Premise Address: Screen Length (from) (to) <br /> Filtet Pack (from) (to) <br /> Well No.: Bentonite' (from) (to) <br /> Grout (from) '(to) <br /> Inspector: Drilling rig typ e <br /> Auger O.D. I.D. <br /> Permit No. Completion- Stove pipe/chnstie box (circle one) <br /> Drilling Company: <br /> ' casing • <br /> Driller: height <br /> Consultant <br /> Geologist t.BOVE-GROUND G#iFtlsil-BOX I, <br /> COhjPLE7�N COMPLEnON <br /> • �_ Cic-ou r�S urf acs • <br /> SPECIAL PERMIT INFO. <br /> prcc.rt <br /> Distance to sewer line <br /> ft- <br /> �- <br /> If yes, location and distance- . <br /> -_ •a 1 <br /> m - <br /> = o <br /> 0 <br /> • In Itad - _ <br /> SA <br /> pack <br /> Holding Temperature - <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/n) <br /> —SPOILS <br /> ' MATERI.AI.S/DEVELOPMENT <br /> Storage Method <br /> Contamination Noted- (y/n) Casing type <br /> Storage Location Blank ft Screen ft- <br /> Slot size <br /> Bags cement <br /> GREG Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter packtype/size <br /> Mix Ratios _____ 5urge_B_lock:._(.y_/_n_) <br /> Installation Method Discussed with geologist: - (y/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 " <br />