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VONITORING WELL INSTALLATION REP# <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 /> Drilling Company; Completion - Stove pipe/christie box (circle one) <br /> Driller: he±qht <br /> casing <br /> �� ,4 <br /> Consultant <br /> Geologist _ T <br /> ABOVE-ORCUND <br /> CONFLETION GMM-80X <br /> SPECIAL PERMIT INFO COMPLETION <br /> �•�.�Ground Satan <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance <br /> • R h. <br /> SAMPLING = a <br /> donad — c <br /> Holding Temperature seclon <br /> Method _ = gnvd�adc <br /> Screening Method c <br /> Tracking Sheet - (y/n ) "i = <br /> SPOILS —ft. <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft, <br /> GROUTING Slot size <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios Bags sand/gravel <br /> -- Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: • (y/ n ) <br /> EH 29 29 Type of method <br />