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_ _ fONITORING WELL INSTALLATION <br /> `" o� I 1 CONSTRUCTION' xf <br /> Date:- �� �' 1 - N3 w <br /> Premise Address: j"L 1 C 1,&YTotal Depth <br /> Screen;Length (from) }U (to) T 4 <br /> 1 ►rV <br /> Well No.: `w r. Filter Pack (from)_ s0 (to) Z <br /> Bentorite (from) 'z (to) z i <br /> Inspector: <br /> W j y Grout (from) 2:N (to) <br /> Drilling rig type Mo b 1, <br /> Permit No. O I �' �' Auger O.D. %l' I.D. " <br /> Completion,-Stove pipe/christie box (circle one) <br /> Drilling Company: V "" E; �• �, <br /> Driller: �'�' `L ��� casing r p^ Y# <br /> height <br /> Consultant r \ <br /> Geologist �0 <br /> } <br /> ABOVE.-GROUND <br /> COMPLEflON `__�CHAZT_Y-80X" <br /> �O��LET10N <br /> SPECIAL PERMIT INFO. Ground Surf'C° <br /> 4c S�oYfA � f 4o sevi ` - grout <br /> Distance to sewer line YO�i •_ <br /> Domestic well on site - (y ZSR { <br /> �vl,lso„ ft. <br /> If yes, location and distance%.J <br /> ZO <br /> a s'S _ '_ Il• <br /> ...� ' {p� .oy�r� � I�t •�i5 �k 'Fs�c �1� <br /> SAMPLING osE , ➢y �' alottad F: <br /> r r aaC�on ` <br /> ' Holding Temperature !} Mwz t gravel pack kf t <br /> Method <br /> Screening Method I <br />:I Tracking Sheet ( y n <br /> SPOILS <br /> Storage Method run S F MATERIALS/DEVELOPMENT <br /> Contamination Noted '- <br /> Storage Location 6 kt j ''� r y Casing type <br /> _ '� ..., , , ;•t . . .: Blank's " ft. Screen, <br /> ti. ( Slot size <br /> GROUTING + �:: ,°` 4 * ��,ti z ags cement c 2 ►/ r <br /> Buckets bentoni ,te' 0, <br /> Depth to water ��tiI 141 Bags sand/gravel <br /> Mix Ratios 1 ►- F z b ,�'�`�� �)Filter Pack type/ ; e <br /> ' Installation Method _ '` }} Surge'Block: - y n ) t <br /> Quantity Installed Discussed with ologist: -(V/ n ) <br /> 1plip <br /> EH 29 29 <br /> Jot <br /> Ok <br /> f <br /> a <br />