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i0 V <br /> ...JNITORING WELL INSTALLATION REPO. <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well NO.. l Jf r 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/christie box (circle one) <br /> Drilling Company: <br /> Driller: cas inq <br /> T height <br /> Consultant 'd <br /> VITA T <br /> Geologist -- <br /> //, 9�A ev <br /> ABOVE-GROUND CHRZTY-BOX <br /> OOhVLErZN COMPLEMN <br /> SPECIAL PERMIT INFO. Gourd Swfacs <br /> Distance to sewer liner//1 grout <br /> Domestic well on site - (y/ n ft. <br /> If yes, location and distance - <br /> M <br /> C <br /> SAMPLING •�cGa� = o <br /> aoincn <br /> Holding Temperature = g,,,d Pack <br /> Method _ <br /> Screenin;Method : <br /> ..0 <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing typejEL �(C <br /> Blank N- ft. Screen 7 o ft. <br /> Slot size 07- 7 <br /> GROUTING Bags cement <br /> Buckets bentonite % St2 <br /> iF <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y{ii <br /> Quantity Installed Discussed with geoTogist: - ( y/ n ) <br /> Type of metliod <br /> EH 29 29 <br />