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("%0NITORING WELL INSTALLATION REPS <br /> Ai. <br /> Date- <br /> CONSTRUCTION <br /> Premise Address: �d V Total Depth 2 <br /> tWell No.: Screen Length .(From) {to) <br /> Filter Pack (from)_ w,� <br /> Inspector: Bentonite (from) —(to) <br /> — Grout (from) r <br /> Permit.No. Drilling rig type C_ [� <br /> Auger O.D. I.D. <br /> Drilling Company: Completion - Stove pipe/cluistie box (circle one) <br /> E: <br /> Driller: 51h�ff<< <br /> casing b�:c <br /> Consultant <br /> hei.ghtr <br /> Geologist <br /> ABOVE-GRCUND <br /> OOMPLETCN GIiFitM43OX <br /> SPECIAL PERMIT INFO. =MPLETICN <br /> Ground Swfa" .,� <br /> Distance to sewer line_ Qrout ; <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - if. <br /> f Y - <br /> $ ...._.ft. <br /> n <br /> SAMPLING I <br /> ' slored <br /> Holding Temperature _ <br /> Method = gr Paas <br /> Screening Method .Y;• <br /> Tracking Sheet (y <br /> SPOILS <br /> Storage Method �? ,(, <br /> MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ nn? ti f �i j <br /> Storage LocatioCasing type 2 <br /> ` B; ft. Screen 27-- ft. <br /> GROUTING Slot size p <br /> a Bags cement , . ..J 4 4 <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation'Method <br /> ". Surge Block: - {y 16) <br /> Quantity Installed <br /> Discussed with geologist: n ) <br /> 'EH 29 29 <br /> Type of method <br />