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i *now <br /> MONITORING WELL INSTALLATION RE1--&T <br /> y �-- s-�y�'�r--�►h <br /> Date: �I J /` CONSTRUCTION/ <br /> Premise Address:— �� _1 Cl} �G� Y oral Depth <br /> Well No.: �-3� V ' Filter �Oe <br /> 1 � � !� Xentonite (to) <br /> �j`,/ (, Grout (from) (to) <br /> Inspector: ,� , <br /> Drilling rig type <br /> Permit No. (. Auger O.D. I• . <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: ( <br /> Driller. 7 ` casing <br /> he <br /> Consultant <br /> //} T <br /> Geologist C - VE-GROUND A <br /> t-TiCN <br /> SPECIAL PERMIT INFO. L i acid Surface <br /> SIMM <br /> Distance to sewer line <br /> -'rod <br /> Domestic well on site - ( y/ ti) <br /> If yes, location and distance �C t it <br /> I - • <br /> SAMPLING <br /> Holding Tem ►' 0y <br /> erature � �• L Cors = �pack�L� 7X <br /> Method <br /> Screening Method 12 <br /> Tracking Sheet - ( y/ n ) <br /> n <br /> SPOILS <br /> l— - <br /> Storage Method %I MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y <br /> Storage Location jCasing type <br /> n L Blank ft. Srseen h- <br /> 11 <br /> GROUTING (� Bags cement I/IV, <br /> - <br /> Bttt. onim`--- • <br /> Depth to water '� -.=�jra°ei <br /> Mix Ratios —Filter-Pack tyWtize <br /> Installation Method Gt e <br /> Quantity Installed sccussed with geg ogisr- - y/. ) <br /> e of method" " <br /> 2929 <br /> • Ply ,' � � �C�- - _ <br /> � � <br />