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(.,;?N1T0R]NG WELL INSTALLATION REI`Au i.. <br /> Date: i i v CONSTRUCE'ION <br /> Premise Address: o�-tilJ ` <br /> /'►" Total Depth <br /> �e Screen Length (from) (to) <br /> Well No.: /� /�W /I/�:L(/ 7 Filtet Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout- ' .1 (from) (to) <br /> Drilling rig We <br /> Permit No. 1 Auger.O.D. ' I.D. <br /> Completion - Stove pipe/cliristie box (circle one) <br /> Drilling Company: .s r <br /> s <br /> Driller: casing <br /> height: <br /> Consultand <br /> ABOVE-GROUND <br /> CO hrF LETION C7-iISTY-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. G,nd S,al,CB e. <br /> Distance to sever line 9roul <br /> Domestic well onsite = ( y / n } l <br /> If yes, location and distance - fl. <br /> ft. <br /> — i <br /> — a <br /> 0 <br /> b <br /> m <br /> C <br /> SAMPLING <br /> i to ctad c <br /> Holding Temperature 1,J <br /> Method <br /> Screening Method — <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 NY <br />