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.MONITORING WELL INSTALLATION RI�ItT <br /> Date:-I/ (allm CONSTRUCTION <br /> Premise Address: Total Depth <br /> Well No.: ,�'• 17r Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Bentonite (from)—(to)- <br /> Inspector: <br /> from) (to)Inspector: Grout (from)-(to)- <br /> Drilling <br /> from) (to)Drilling rig type <br /> Permit No. Auger O.D. I.D- <br /> Drilling Company: /%1-�`�S l i/1� <br /> /p Completion - Stove pipe/christie box (circle one) <br /> , <br /> Driller: �� casing <br /> height <br /> ConsultantLnnT <br /> Geologist ,°l INT <br /> ABOVE-GROUND <br /> COhPLETION CHRIM43OX <br /> COMPLE71ON <br /> SPECIAL PERMIT INFO. Gond Sur{xy <br /> Distance to sewer line Oran <br /> Domestic well on site - (y/n ) �—n <br /> If yes, location and distance - <br /> n. <br /> n. <br /> q = <br /> O <br /> O <br /> SAMPLING abnad _ 8 <br /> soc5on <br /> Holding Ter)tperature w <br /> Method / " — gr'vio Pack <br /> Screening Method — <br /> Tracking Sheet - (y/n) <br /> L n. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen fr. <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 />