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MONITORING WELL INSTALLATION REPW <br /> Date: "0 i/n' CONSTRUCTION <br /> Premise Address: 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 /> height <br /> —ErVT <br /> Consultant �ld�-J"y.'�^ <br /> Geologist <br /> ABOVE-GROUND CHRIS7Y-BOX <br /> CObIPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surfaca <br /> Distance to sewer line gro"l <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - tt <br /> o <br /> C <br /> O <br /> SAMPLING abttad <br /> taction <br /> Holding Temperature V',,d Pack <br /> Method <br /> Screening Method r' <br /> Tracking Sheet - (y/ n ) <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 />