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GONITORING WELL INSTALLATION REPAS <br /> Date: zr qh CONSTRUCTION <br /> Premise Address: 7 >/ ♦ti Total Depth <br /> Well No.: wtb7 Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> f1�, pQ Q Bentonite (from) (to) fo <br /> Inspector: _T �" \ Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> n I <br /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> �_ _ <br /> Driller: casing <br /> Consultantheight_ }'ph� T <br /> Geologist <br /> _ T <br /> ABOVE-GROUND <br /> COMPLETION CHRM Y-BOX <br /> SPECIAL PERMIT INFO. OCOMPLETION <br /> round Susan <br /> Distance to sewer line Grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - <br /> SAMPLING = o <br /> tlattad = 'c <br /> Holding Temperature ` � auction <br /> — <br /> Method = gravel pads <br /> Screening Method = <br /> Tracking Sheet - ( y/ n ) _ <br /> _ R. <br /> SPOILS <br /> Storage Method M_ ATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type Z VPdb <br /> Blank (0 ft. Screen <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth twater /� Bags sand/gravel I <br /> Mix Ratios Filter Pack type/size 177 <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/n) <br /> EH 29 29 Type of method <br />