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lo <br /> r MONITORING WELL INSTALLATION ROORT <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. 0442:!,,fD Grout (from) (to) <br /> Drilling rig type <br /> Permit No._ Auger O.D. I.D. <br /> Completion - Stove pipe/clu•istie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> �� height <br /> Consultant �. s 'd <br /> Geologist <br /> ABCVE-GROUND CHMM-Sox <br /> COMPLETION COMPLETICN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - (y/ n) <br /> If yes,location and distance - ft. <br /> tt. <br /> V' O <br /> SAMPLING slored = <br /> M = 3 <br /> sorlcn �•• — <br /> Holding Temperature <br /> Method a• = QM 91 D� <br /> :u. <br /> Screening Method : <br /> Tracking Sheet - (y/ n ) — <br /> a._._.....ft. L-J ft. <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 Metl•:od Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />