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�- .fONITORING WELL INSTALLATION REP(>m. <br /> Date: l� 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. T.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> iT height <br /> Consultant _ZWT <br /> Geologist •- <br /> ABOVE-GROUND CHRIM43OX <br /> OOMPLEf ION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surfwa <br /> Distance to sewer line grout <br /> Domestic well on site - {y/n ) <br /> n. <br /> If yes, location and distance - <br /> (t. <br /> Vis.'.. <br /> SAMP NG <br /> ascuan <br /> Holding Temperature <br /> Method = <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS <br /> Storage Method `""[ — MATERIALS/DEVELOPMENT <br /> Contamination N - ( 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 wate_a/ _ 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 />