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MONITORING WELL INSTALLATION FORT <br /> DateCONSTRUCTION <br /> : � / <br /> Total Depth (to) <br /> Premise Address: Screen Length (from) — <br /> Filter Pack (from) (to) <br /> Well No.: <br /> W-"Z Bentonite (from) (Co) <br /> . Grout (from) (t0) <br /> Inspector. Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> L casing <br /> Driller. –:F height <br /> i5 <br /> Consultant—L!::'• <br /> Geologist ABcvE-GRCUND Cl-tRZTY-Box <br /> COh3PLETION C0MPL-'T1CN <br /> G=rd Suiaas <br /> SPECIAL PERMIT INFO• grout <br /> Distance to sewer line <br /> Domestic well on site .- (y/ n) ft. <br /> if yes, location and distance - eft. <br /> _ O <br /> &lot•.Q.� <br /> SAMPLING = <br /> :ocicn <br /> Holding Temperature <br /> Method <br /> Screening Method •. _ , <br /> Tracking Sheet - (Y/n) cltt• <br /> ft. <br /> To el <br /> SPOILS <br /> MATERI ALS/DEVEi.OPMENT <br /> Storage Method k 4/ <br /> Contamination Noted - (y/ n) Casing type 5 ce <br /> Storage Location Blank 5 0 <br /> ft. Screen ft. <br /> Slot size cs•0 2v <br /> Bags cement <br /> GROUPING Buckets bentonite <br /> Bags sand/gravell <br /> Depth to water. Filter Pack type/size, �" <br /> Mix Ratios Surge Block: - (Y/tl ) <br /> Jpstallation Method Discussed with geologist: - (y/ n <br /> Quantity Installed Type of method <br /> EH 29 29 <br />