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MONITORING WELL INSTALLATION R.Epore° <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: casing <br /> height <br /> Consultant T <br /> T <br /> Geologist A80VE-GRCUND <br /> COMP1.ETiON Ci�RtSTY-30X <br /> COMPL-=MCN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - n- <br /> = Q <br /> SAMPLING •Ior.Ai <br /> ^ — 3 <br /> aecicn — <br /> Holding Temperature = __ prava Pack <br /> Method _ — <br /> Screening Method :` — <br /> Tracking Shcet - ( 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 Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed _ Discussed with geologist: - (y/ n ) <br /> Type of metliod <br /> EH 29 29 <br />