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QNITORING WELL INSTALLATION REP016ii' <br /> s M <br />�r Date: CONSTRUCTION <br /> t Premise Address: / d0 "" G " '' Total Depth <br /> // Screen Length (from) (to) <br /> Well No.: /I.2-1Y Filter Pack (from) (to) <br /> Bentonite (from)-(to)- <br /> Inspector: <br /> from) (to)Inspector: .717 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: i <br /> Driller: _ casing <br /> '• / jffT <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE-GROUND <br /> COMPLETION CHRZTY43OX 1 <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Grourd SuAacw <br /> Distance to sewer line grout j <br /> Domestic well on site - (y/ n ) 1 ft I <br /> If yes, location and distance - <br /> ft. <br /> ft. � <br /> = o i <br /> . — c <br /> SAMPLING = ° <br /> slotted c <br /> (lbG s.c5on <br /> Holding Temperature 7 <br /> Method = g'V9'PackP <br /> Screening Method =, _ <br /> Tracking Sheet - (y/ n ) x: <br /> ft. = 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 /> I EH 29 29 <br /> i <br />