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MONITORING WELL INSTALLATION REP# <br /> Date: CONSTRUCTION <br /> i <br /> Premise Address: <br /> Total Depth <br /> Screen Length (from) (to) <br /> Well No.: '� " � `�t # Filter Pack (from) (to) <br /> K ��^ Bentonite (from) (to) <br /> Inspector: }' , Grout <br /> (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> Driller: casing <br /> ��. height <br /> Consultant <br /> Geologist 44 V <br /> ABOVE-GROUND _ <br /> COMPLETION CHRiS7Y-BOXGroundSPECIAL PERMIT INFO. Ggur{xy COMPLEnON <br /> Distance to sewer line "Out <br /> Domestic well on site - ( y/ n) <br /> If yes, location and distance - 7 V- <br /> tt• <br /> tt. <br /> V. <br /> a <br /> = m <br /> — e <br /> _ <br /> = r <br /> c <br /> SAMPLING <br /> _ o <br /> slotted = 8 <br /> sac4on — <br /> Holding Temperature <br /> Method = flf1BIPack <br /> Screening Method =_ <br /> Tracking Sheet - (y/ n ) <br /> — tt. <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 />