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1 l�ONITORING WELL INST TION RER 1 <br /> I <br /> Date: Z S'e. CONSTRUCTION ► <br /> Total Depth <br /> Premise Address: ""`"`-' <br /> Screen Length (from) (to)__,_ <br /> Well No.: Filter Pack (from) (to) ,."Ilk <br /> Bentonite (from)_ (to) a <br /> Inspector: <br /> Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. <br /> Completion - Stove pipe/christie box (circle one) ; <br /> Drilling Company: <br /> Driller; <br /> casing r 4 <br /> � T <br /> height <br /> Consultant 6 . .. . <br /> Geologist <br /> ABOVE-GRCIJND CNRz Y-80X <br /> CONFLEI'IGN <br /> COMPLETION <br /> SPECIAL PERMIT INFO, ( rmAl Suoacs <br /> � <br /> Distance to sewer line Qroutrc <br /> Domestic well on site - (y/ n) ' ft. <br /> If yes, location and distance - <br /> ft. <br /> SAMPLING <br /> sod <br /> cn <br /> Holding Tem erature { pMvoi pa* <br /> Method VP ^ — <br /> Screening Method <br /> .s. <br /> Tracking Sheet - / n) _ <br /> SPOILS <br /> Storage Method �f�- MATERIALS/DEVELOPMENT <br /> Contamination Noted';­(y.%'n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> SIot size <br /> GROUTING . Bags cement <br /> Buckets bentonite <br /> Depth to water �-. Bags sand/gravel <br /> Mix Ratios ' -t' .` '!t X17. °-Filter Pack'.type/size <br /> Installation Method <br /> Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />