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M .rtONITORING WELL INSTALLATION REpv,i r <br /> Date: 7�� CONSTRUCnON <br /> Premise Address : / 7s �✓t'^ K Total Depth <br /> Screen Length (from) (to) <br /> Well No. : Filter Pack (from) (to) <br /> Bentonite (from) ([o) <br /> Inspector. [ ' Grout (from) P (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: casing <br /> �, �/,.,,� height <br /> Consultant <br /> Geologist "p t \ i x /Vu ?p vt: <br /> ABOVE-GRCUND <br /> COWLETION ChA SIY30X <br /> COh4PL.ETION <br /> SPECIAL PERMIT INFO. Orwrd S zixr <br /> Distance to sewer line preen <br /> Domestic well on site - ( y / n ) It <br /> If yes, location and distance - <br /> fto <br /> tt. <br /> vy = a <br /> SAMPLING �IonAi <br /> soccn - —_ <br /> Holding Temperature = ,I <br /> Method — F <br /> Screening 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. Screenftp <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water 3 �. 30 �° 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 />