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RJ <br /> 4MONITORING WELL INSTALLATION REI-.. T <br /> Date: 1 ` r - Z&V-V CONSTRUCTION <br /> r <br /> Total Depth "© Vj <br /> Premise Address: S� ` ` r Soman Length (from)---6-0 (to) <br /> Well No.: I 1 " Filter Pack (from) Y'F (t ) <br /> Grout (from) <br /> QQqq��� j�p Bentonite (gym)--�--(m) <br /> r. o <br /> Inspecto /(y r <br /> Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. ,p Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: p � <br /> ��� casing <br /> Driller. height Consultant 7* <br /> VF/) <br /> Geologist ZU ABOVE-GROUND CHR1Sry-aox <br /> CCCk PLEMN CCMPSLSi1CN <br /> ���Csattnd Spat <br /> SPECIAL PERMIT INFO. <br /> Ott <br /> Distance to sewer line S ,t <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - ft. fL <br /> 3 <br /> - a <br /> — o <br /> tbnYd _ c <br /> SAMPLING <br /> on <br /> Holding Temperature =_ LtL <br /> Method <br /> Screening Method —Tracking Sheet - (y/ n <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method v(I <br /> Contamination Noted - (y/ n) Casing type Ff n L <br /> Storage Location Blank j ft, Screen fr. <br /> Slot size (v <br /> GROUTING Bags cement 1-3 <br /> � vJQ�i v✓aS Buckets bentonite z <br /> f a Fl u ���� Bags sand/gravel <br /> Depth to water U`'` Filter Pack typesize <br /> Mix Ratios Surge Block: - C y/ <br /> Installation Method Discussed with geol r. - ( y/ a) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />