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%.,;VIONITORING WELL INSTALLATION REI.,,,OT <br /> Date: lJ l <br /> CONSTRUCTION <br /> Premise Address: 3 Total Depth <br /> r� 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 /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> Driller: casing <br /> height <br /> Consultant <br /> LITA <br /> Geologist T <br /> Ai&E-GROUND <br /> COAPLETCN CBFi M-sox <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line Of°ul <br /> Domestic well on site - {y/ n <br /> If yes, location and distance - <br /> ` tt. <br /> tt. <br /> m <br /> q <br /> SAMPLING <br /> slonad E <br /> soc�a n <br /> Holding Temperature <br /> Method — 7"'W pack <br /> Screening Method _ <br /> Tracking Sheet - (y/ n ) <br /> Z. <br /> {t -_ l+. <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 />