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%.—sONITORING WELL INSTALLATION REPL,_� <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/christie box (circle one) <br /> Drilling Company- <br /> Driller: oa9 ing <br /> height <br /> Consultant <br /> Geologist - <br /> AiOV -GSCVND CHRIS 43OX <br /> COMPLETION COMPLEnON <br /> SPECIAL PERMIT INFO. Ground Surfaco <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - (y/ n) �,_„ �ft. <br /> If yes, location and distance - M <br /> ft. <br /> SAMPLING <br /> 3 <br /> aacdcn �i, — <br /> Holding Temperature <br /> Method " — s� <br /> M = <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 /> Blank ft. Screen ft. <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 />