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ONITORING 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 /> Ot- ( ^ liltheight <br /> Consultant >/!� <br /> n <br /> -W-F <br /> j- <br /> s /1BOVE-GFCUND <br /> COMPLETION COMPLETION <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Sul'c <br /> Ori <br /> Distance to sewer line PIZ <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - ft. <br /> tt. _ <br /> Y.. <br /> V' <br /> _ O <br /> SAMPLING dorod = <br /> saricn <br /> Holding Temperature Fack <br /> Method <br /> Screening Method — <br /> Tracking Sheet - (y/ n ) F = <br /> n. = tt. <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 Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />