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MONITORING WELL INSTALLATION OORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from)• (to) <br /> Well No.: Filter Pack (from) Cto) <br /> Bentonite' (from) Cto) <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 /> Consultant —� <br /> - T <br /> Geologist <br /> ABOVE-GFOUND <br /> cohiPLEi}ON CNAISTYTiOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. <br /> pra.�t <br /> Distance to sewer line <br /> Domestic well on site - C y/n) h. <br /> If yes, location and distance- ft. <br /> • ft. <br /> m <br /> = o <br /> SAMPLING . slotted <br /> tac4on Y = <br /> Holding Temperature = p-+ d packMethod <br /> Screening Method . <br /> Tracking Sheet - C y/n) _ <br /> tt. = it. <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__--_--------!!.-- <br /> — -- . ... <br /> Quantity Installed <br /> Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br />