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)NITORING WELL INSTALLATION REP/"Q-'r <br /> E" '%qo <br /> LL <br /> Date: + CONSTRUCTION <br /> Premise Address: <br /> (i Total Depth <br /> j� Screen Length (from) (to) <br /> Well No.: "� � Filter Pack (from) to <br /> ' Bentonite (from) (to) <br /> Inspector: 1 ! Grout (fro <br /> Drilling rig type <br /> Permit No. Auger O.D. 21/ _ T.D. <br /> 41 <br /> ,% t-yQompletion • Stove pipe/christie box (circle one) <br /> Drilling Company: w®a "- " <br /> Driller: ; �'ti'` od g <br /> height <br /> Consultant —WV <br /> 7F <br /> Geologist --' <br /> ABOVE-GROUND OHR=Y-80X <br /> I k t 'zs a n COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Sona:* <br /> Distance to sewer line grout <br /> Domestic well on site - (y 1 n) <br /> If yes, location and distance - ft. <br /> ft. <br /> SAMPLING siotsod <br /> wc'ron <br /> Holding Temperature �„ park <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/n ) <br /> SPOILS <br /> Storage Method " �''�"�'t '�� MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type T U <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 /> EH 29 29 <br /> 41��` ,�, Type of method <br /> ` <br />