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MONITORING WELL INSTALLATION R � RT <br /> Date:J/ /0 � ,1 - CONSTRUCTION <br /> Premise Address : �7 � �l� L l2 /� Total Depth <br /> 8 A W 5 / � , Q p Screen Length (from) (to) <br /> Well No.: , `" Filter Pack (from) <br /> (to) <br /> Bentonite (from) (to) <br /> Inspector: ntis t� Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: <br /> Completion - Stove pipe/ 'stie box (cir <br /> Driller: cas i <br /> heig t <br /> Consultan <br /> 9 gist fz , <br /> ABOVE-GROUND <br /> OOAPLETnN CHR T BOX <br /> SPECIAL PERMIT INFO. COMPLETION <br /> nd Swlace <br /> Distance to sewer line grout <br /> Domestic well on site - ( y / n ) l <br /> If yes,- location and distance - b fta <br /> ft ft. <br /> — m <br /> SAMPLING — `o <br /> slotted — c <br /> &&clanHolding Temperature. <br /> Method IkjmAkp = Gr+rrei pack <br /> Screening Method = <br /> Tracking Sheet - ( y / n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y / n ) <br /> Storage Location Casing type <br /> Blankft. Screen ft, <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water �'bS <br /> Bags sand/gravel <br /> Mix Ratios Filter Pack type/ ize <br /> Installation Method Surge Block: - y / n ) <br /> Quantity Installed Discussed with geologist: . ( y / n ) <br /> EH 29 29 <br /> Type of method <br /> i <br />