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mONiTORING WELL INSTALLATION REPO <br /> Date: CONSTRUCTION <br /> Premise Address: / Is J �j� /(/,\�tx a Total Depth <br /> Screen Length (from) 161X- (to) /Z <br /> Well No.: Filter Pack (from) /Y/ (to)/ <br /> Bentonite (from) / L.r-, (to) 1/6 <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I. . <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: � pie 6ZWi <br /> Driller: he4 ht <br /> Consultant /1� -i- <br /> Geologist r <br /> CUND <br /> FLE <br /> WC-iRI Y-aoX <br /> CCMPLRION COWLE'nCN <br /> SPECIAL PERMIT INFO. Ground Strfac� <br /> Distance to sewer line Grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft <br /> ft.. <br /> h. <br /> = m <br /> = o <br /> SAMPLING �lorad <br /> soden <br /> Holding Temperature <br /> Method = <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> tt. _ ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELCPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type 2 ` f <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water v �( Bags sand/gravel <br /> Mix Ratios Filter Pack type/ 'ze <br /> Installation Method PVVV"' Surge Block: -- / n ) <br /> Quantity Installed .---7tto - Discussed with eologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />