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MONITORING WELL INSTALLATION REPO <br /> Date:6-� CONSTRUCTION <br /> Premise Address: Total Depth <br /> / Screen Length (from)-(to)- <br /> Well <br /> from) (to)Well No.: r I Filter Pack (from) (to) <br /> Bentonite (from)_(to)- <br /> Inspector <br /> from) (to)Inspector. Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: 111 casing <br /> he-ight <br /> ConsultantT <br /> Geologist - T <br /> ABCVE-GACUND Ct(AISTY•80X <br /> CONFLET1CN CCMPLEnCN <br /> SPECIAL PERMIT INFO. Ground Surface Tom` <br /> Distance to sewer line PIZ <br /> Oran <br /> Domestic well on site • ( y/ n ) ft. <br /> If yes, location and distance - ft. <br /> ft. <br /> ,ai = <br /> — o <br /> SAMPLING monad = <br /> sucicnF = <br /> Holding Temperature y L _ _ Xkpa <br /> Method "i _= <br /> Screening Method <br /> Tracking Shcet - ( 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 />