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.ONITORING WELL INSTALLATION REK , <br /> Date: CONSTRUCTION <br /> Premise Address: Total Deptai <br /> Screen Lent' (from)__ {to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (ft um) (to) <br /> Inspector: Grout (f:orn) (to) <br /> Drilling rig type <br /> Permit No, Auger O.U. I.D. <br /> Completion - Stove pipe/christie bort (circle one) <br /> Drilling Company: <br /> Driller: cal=ng <br /> Consultant <br /> Geologist •- ,� <br /> e 3VE GRC4l 1ND Q-S*1r`f-B0X <br /> 0C&F Er CN COMPLE'MCN <br /> SPECIAL PERMIT INFO. Ground Si l2c* � <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - ( y/ n ) ft <br /> If yes, location and distance - ' <br /> Y. <br /> C <br /> SAMPLING n =' <br /> Holding Temperature <br /> Method ¢sval pacts <br /> Screening Method _ <br /> Tracking Sheet - ( y/ n ) <br /> tt- I F Ltoo <br /> SPOILS <br /> Storage Medd od MAT RIA.LSd EVELOPMENT <br /> Contamination Noted - { y/ n ) <br /> Storage Location Casing type: <br /> Blank ft. Screen ft. <br /> Slut size_ �­ <br /> GROU 17NG Bags semen <br /> Buckets bcntonite <br /> Depth to water Bags sand/g-mvcl� <br /> Mix Ratios—--- Filter Tack tjpe/size. <br /> Installation Method_ surge :dock.: • ;a r I r: <br /> Quantity Installed Discussed v i.t i geologisr: - { y/ n ) <br /> Type of method_ ._ <br /> FH 29 29 <br />