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OONITORING WELL INSTALLATION OR1* <br /> Date: CONSTRUCTI N c <br /> Premise Address: - Total Depth l <br /> Screen Length (from) ? ( <br /> Well No.: AkLZ Filter Pack (from) `7 r <br /> Bentonite (from) (to) <br /> Inspector. Grout (from) G 3 (to) <br /> JDrilling rig type Ci/7 �- r I-cr%(vti✓' _ -- <br /> Permit No. Auger O.D. 5'`/y I.D. <br /> Completion - Stove pipe/clu'istie box (circle one) <br /> Drilling Company- <br /> Driller: <br /> Driller: eta.A ea�� <br /> casing <br /> height <br /> Consultant <br /> Geologist \I '- <br /> ABCVE-GF1C JND iSTY-30X <br /> C06�AL TCN L`TICN <br /> SPECIAL PERMIT INFO. ' <br /> Distance to sewer line orart <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - ft. <br /> ft. <br /> C <br /> SAMPLING ilorai <br /> &ocicn <br /> Holding Temperature _` _ gnV14 Pack <br /> Method = <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/6) /10 <br /> Storage Location 3,-L.( Casing type <br /> Blank fr. Screen h• <br /> Slot size - c - <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios ZFilter Pack type/size <br /> Installation Method C a ' Surge Block: - 0/ n ) <br /> Quantity Installed Discussed with geologist: - (C/ n ) <br /> Type of mediod <br /> EH 29 29 <br />