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Siyh CID JNITORING WELL INSTALLATION REPC <br /> V <br /> Date: CONSTRUCTION <br /> Premise Address: 1�c Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> /� Bentonite (from) (to) <br /> Inspector: P ✓�4 Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> C Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: 4,u <br /> casing <br /> Driller: T g <br /> C�� T height <br /> Consultant � <br /> Geologist <br /> ABOVE-GROUND C_[RZrY-8OX <br /> CONFLE ZN COMPLETION <br /> SPECIAL PERMIT INFO. G=nd Surface <br /> Distance to sewer line i�" ` '`� grout <br /> Domestic well on site - (y/n ft. <br /> If yes, location and distance - <br /> �. ft. <br /> SAMPLING sbnod _ <br /> r!6 v socicn <br /> Holding T perature 7� <br /> Method x _ �F <br /> Screening Method P L <br /> Tracking Sheet y/ n ) <br /> " M <br /> LJ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination N ted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> JBuckets bentonite <br /> Depth to water - � c'4' S Bags sand/gravel <br /> Mix Ratios, _, r_�, Cpiw� Filter Pack type/size <br /> Installation Method -c•_ t.• T'- �-�� Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - n) <br /> Type of method V <br /> EH 29 29 <br />