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&NITORING WELL INSTALLATION REPAS <br /> Date: 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/clrristie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant '4 <br /> Geologist T <br /> ABOVE-GROUND Cifii1STY 80X <br /> COA4�L ETK)N COWLETICN <br /> SPECIAL PERMIT INFO. Ground g�{ycy <br /> Distance to sewer line Orcut 1 <br /> Domestic well on site - (y/ n ) _7 ft. <br /> If yes, location and distance - <br /> ft. <br /> ft. <br /> SAMPLING = ` <br /> 0 <br /> donod = �c <br /> aaeicn <br /> Holding Temperature <br /> Method <br /> Screening Method 211 —_ <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 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 /> Method <br /> Installation Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> EH 29 29 Type of method <br />