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MONITORING WELL INSTALLATION REF <br />4 <br />CONSTRUCTION <br />Date: <br />Total Depth 4 , <br />Premise Address:(to) <br />Screen Length (from)- (to) <br />T , 1.� Filter Pack (from) ' (to)_ <br />Well No.: ' «� ,t ";' <br />2 Bentonite- [ <br />Grout (from) <br />Inspector: Drilling rig type <br />w _ _ Auger O.D. _', "k J.D. <br />Permit No, Completion =Stove pipe/christie box- [circle one) `. <br />Drilling Company, <br />casing <br />Driller: ' ;' f" height <br />Consultant <br />Geologist J1801IE-GROUND N - CHRrSTY-BOX <br />.. _ COMP!_ETON <br />COMPLETION <br />[ifCUCld $L�3Ct <br />'SPECIAL PERMIT INFO." '. .... , <br />„ <br />3 �y <br />S <br />grocrt <br />Distance' to sewer line <br />Domestic well on site (y <br />if yes, location and distance <br />e <br />SAMPLING <br />Holding Temperature <br />Method <br />Screening .Method <br />i Tracking Sheet - ( y / n) <br />"Storage Method <br />C tamination Noted- (y / n ) <br />a <br />MATERIALS/DEVELOPMENT <br />V" <br />'Storage Location �- •-�� - � Casing typ <br />e <br />I Blankft. Screen _ft. <br />Slot size <br />GROUTING Bags cement <br />Buckets bentonite <br />Depth to water Bags sand/gravel <br />Mix Ratios �` - , Filter Pack types <br />ize <br />Ir - Installation Method Surge Block: - (y / n } <br />Quantity Installed Discussed with geologist: - ( y / n ). <br />Type of method <br />EH 29 29 <br />All '�a ` <br />