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MONITORING WELL INSTALLATION A! RT <br /> Date: -4 �� 1 °� CONSTRUCTION <br /> Premise Address: 11-o-( j5 54'%- � Total Depth O <br /> Screen Length (from) !10 (to) 1) 0 <br /> Well No.: 1pn (AI •1 �' Filter Pack (from) i i (to) 40 <br /> Bentonite (from) 3 6 (to) sf <br /> Inspector. Grout (from) (to) X6 <br /> DrMing rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion•Stove pipe/christie boa (circle one) <br /> DrMing Company: <br /> Driller. (�o�•�7dL __ casing <br /> he, <br /> Consultant C m <br /> 77 <br /> Geologist .r./ ted` Jt3CVE-GRCUt+tC <br /> C,.^ArP�T,ON CHRt5'�Y-3CX <br /> C_—MP!_i ICN <br /> SPECIAL PF_1UW. i'INFO. CU-jund&x1'" <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - - fL <br /> _ a <br /> SANLpl.INC <br /> .F = <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - C y/ n) l = <br /> SPOIIS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) Casing type .L 10 V c <br /> Storage Location Blank �a Screen---Sft <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> ' Bags sand/grave dQ <br /> Depth to ware_- 'y `�5 Filter Pack typesize -2-1(2- �e� <br /> Mix Ratios Surge Bloc3c - C y <br /> Installation Method Discussed with geolom - C Y/� <br /> Quantity Installed N Type of method <br /> EH 29 29 <br />