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MONITORING WEm INSTALLATION RM--AT <br /> CONSTIL C QN 1 <br /> Date, '-Z _ �J <br /> Premise Address: Ot? Total Depth <br /> screen Length (>xam) (to)� <br /> Well No.: W Filter Park (front) (m) <br /> �e r Bentonite (from) (to) <br /> (nspector. -�' Grout (from) to).�... <br /> DnUing rig type <br /> Auger O.D. <br /> Permit No. I.D. <br /> M Completion-Stove pipe/christie box (circle one) <br /> Drilling Compan3r. •� <br /> casi-ng <br /> Driller: w7rl he;ghc <br /> Consultant <br /> Geologist j ABOVE-GROUND Cj�.aox ' <br /> ccWLEMN Com_—;mm <br /> cdc d Surfacm <br /> SPECIAL PERMT INFO. <br /> Distance to sewer line <br /> Domestic well on site - C Y/. a ) Ian If yes, location and distance - n- <br /> 4 a <br /> 5 <br /> iso' <br /> SAWLING <br /> Holding Temperature <br /> Screening Method 112 <br /> Tracking Sheet - (y/ n) <br /> t4 .pear <br /> SPOM i4_0*�. ` M TMW/DEVELOPMENT <br /> Storage Method `h W ez t <br /> Contamination Noted - (y/ a) Casing type (� <br /> Storage Location Blank k Screen <br /> Slot site <br /> QUTIBags cement <br /> GSA r Buckets bentoniu <br /> Depth to water Sags sand/gtavd <br /> F$ter Pack <br /> Mix type site <br /> installation Method Surge Block: - {y/m) <br /> Quantity Installed Discussed with geologist: - C Y/ n) <br /> Type of method <br /> EH 29 29 <br />