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MONITORING wELL INSTALLATION REl--rLT <br /> Dace: CONSTRUCTION 1 <br /> Q f f <br /> Premise Address: " `1 C �d( CSw `�� Total Depth <br /> ' Screen Length (from) i(to) <br /> \ Filter Pack (from)�a�—(to) G1 3 <br /> Well No.: Bentonite (from) (to) Ll-o <br /> Grout (from) (to) <br /> Inspector. Drilling rig type <br /> Auger O.D. I-D. <br /> ?ermir No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company. <br /> casing <br /> Driller•. height <br /> V1771 V <br /> Consultant � <br /> Geologist AWVE.GACUNO CHSLS;v.3Ox - <br /> '��T�N 0--Wt.TCN <br /> SPECIAL PERMIT INFO. <br /> r �out <br /> Distance to sewer line <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - ( J <br /> I � _ <br /> SAMPLING f 2 G a l I lo ad <br /> ween <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - C y/ n ) 1 <br /> Q c10r IL � = t tt. <br /> SPOILS r�p <br /> MATERIALS/DEVELOPMENT <br /> Storage Method <br /> Contamination Noted - (y/ n) L Casing type <br /> Storage Location 1 �LS Blarik ft Screen —ft. <br /> l Slot size <br /> GROUTING Bags cemen[ <br /> Buckets bentonite <br /> LC Bags sand/gravel <br /> Depth to water Fater Pack type/size <br /> Mix Ratios Surge Block: - C y/ n ) <br /> Installation Method Discussed with geologist - C y/ a ) <br /> Quantity Installed Type of method <br /> EH 29 29 H, d W� <br />