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_JNITORING WELL INSTALLATION REPO. <br /> Date: 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. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant =71 IV <br /> 7//, M T <br /> Geologist <br /> ABCVE-GACUND CNASST'Y-80X <br /> COMPLEET{ON COMPLEEMCN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line <br /> proof <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft. <br /> —L-7— <br /> ft, <br /> SAMPLING •�ct:a� = c <br /> ioctcn <br /> Holding Temperature = Gr+v-w Pack <br /> Method <br /> Screenin;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 /> GROUPING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size -t G -� <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />