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! <br /> A�MONITORING WELL INSTALLATION RE T <br /> r � <br /> Date: CONSTRUCTION <br /> �✓ <br />` Premise Address: Z S�l TotalDeptli' <br /> Screen Length (from) (to) Z3 <br /> Well No.: r <br /> FiltePack !! (from) (to) <br /> y ! <br /> Bentonite (from) (to) �- <br /> �- <br /> j 1 <br /> Inspector: S'e._ �[ Grout �1 (from) c� [to) U <br /> Drillin rig,: e <br /> StYP � 1 <br /> Permit No. Auger O.D.i �' '�T I.D. <br /> Completion!- Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: M casing <br /> Tl� <br /> height <br /> Consultant <br /> Geologist----- � '11�' A80VE-GROUND i <br /> COMPL1wTION C�iFiWY-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. I 5' ~" 'M01 # i� G=nd Surf <br /> qi <br /> Distance to sewer line 5 <br /> Domestic well on site - [y/ nS - <br /> If yes, location and distance - �I <br /> SAMPLING PI[� 15-- <br /> J `v� F�� °°l% a <br /> ott''an <br /> Holding Temperature I c F� ice Sb -2 <br /> Method J �SI 4 p UlM l gmval Pads <br /> Screening Method_ <br /> Tracking Sheet - (y/n2 7 <br /> rpm � n <br /> SPOILS <br /> Storage Method dr MATERIALS DEVELOPMENT <br /> Contamination Noted - (y%L4 <br /> i`` I <br /> i: T1 /' VStorage LocationCasing type <br /> Blank 0 — ft. Screen ft. <br /> Slot size 1I _ OZO <br /> GROUTING Bags;�cement - �L�t <br /> 1 Buckets bentonite <br /> Depth to water �'c8 Bags'�sand/gravel z 1- <br /> r <br /> Mix Ratios Filter Pack "' e'ze <br /> Installation Method Surge Block;- (YJ n } <br /> Quantity Installed Discussed viii ologist: - (y/ <br /> Type:�of method - <br /> EH 29 29 ( I ! <br /> s <br /> Ps14 / �v ) ! <br />