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%.JNITORING WELL INSTALLATION REPO <br /> Date:l Z CONSTRUCTION <br /> Premise Address: IDJ�D S. �/�v(c� Total Depth <br /> 601�V#f �aJ 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 /> Drilling Company: Completion - Stove pipe/cluistie box (circle one) <br /> Driller: casing <br /> M height <br /> Consultant Gl//C <br /> -EWTGeologist <br /> ABOVEGROUND GiAtSrY80X <br /> COMPLEf10N COMPLEnoN <br /> SPECIAL PERMIT INFO. Grourd Su fan <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - <br /> R tt. <br /> w <br /> o <br /> SAMPLING <br /> slonwi _ <br /> sacicn <br /> Holding Temperature �� <br /> Method ;' <br /> Pack <br /> Screening Method <br /> Tracking Sheet - (y/ n ) 7 <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 />