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JNITORING WELL INSTALLATION REPuAT <br /> Date:/ CONSTRUCTION <br /> Premise Address : AW 47� Jf(L Total Depth <br /> 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 /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> e � height <br /> Consultant <br /> Geologist <br /> ABDVEGAC(JND CNA15i ( 80X <br /> �AFLEfbN CCMPLETICN <br /> SPECIAL PERMIT INFO. G=nd Sumac" <br /> Distance to sewer line "rout <br /> Domestic well on site - ( y / n ) It. <br /> If yes, location and distance - <br /> d�ft. ft. <br /> SAMPLING <br /> doral = � <br /> socicn <br /> Holding Temperature = "ravdpaat <br /> Method = <br /> Screening Method <br /> Tracking Sheet - ( y / n ) ' _ <br /> tt. - M <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 />