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`10NITORING WELL INSTALLATION REPC- r <br /> Date: t� 1.�l?'4 6�? CONSTRUCTION <br /> Premise Address: 5-10 td' °Q" y Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: h�1� 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 /> Geologist <br /> ABOVE-GROUND <br /> CCNAISTY-80X <br /> COMPLETION <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Omand Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n ) tt, <br /> If yes, location and distance - tt, <br /> tt. <br /> r. C <br /> O <br /> SAMPLING tlottpd Y = c <br /> Holding Temperature <br /> Method ��P� <br /> �. — <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 <br />