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MONITORING WELL INSTALLATION <br /> r <br /> CONSTRUCTION <br /> Dace: <br /> 10 2, b <br /> ' II Total Depth <br /> premise Address: 3s N Screen Length (from) (to)__ <br /> Filter Pack (from) (to) <br /> Well No.: 0 — Bentonite (from) (to)__ <br /> Grout (from) (t°) - <br /> tnspector. Drilling rig type <br /> Auger O-D- I D <br /> Permit No. a Complerion - Stove pipe/chrisrie box (circle one) <br /> Drilling Company: <br /> AAl 1 <br /> casing <br /> Driller. height <br /> Consultant <br /> Geologist ABCVE-GRCUNO cl-SZ11-8CX <br /> C—C&F ET1CN C_-+dPS=i,CN <br /> Gcnc,trd Suf ata <br /> SPECIAL PERMIT—INFO- <br /> Distance <br /> NFO•Distance to sewer line ♦ `t. <br /> Domestic well on site - ( y/ n ) fL <br /> if yes, location and distance <br /> 3 <br /> _ o <br /> a <br /> SAMPLING sac;cn _ <br /> Holding Te? perature b f; <br /> Method <br /> Screening Method <br /> Tracking Sheet y n ) ,L �► = T tL <br /> SPOILS <br /> MATZRIALS/DEVELOPMENT <br /> Storage Method / <br /> Contamination Noted - (y/ n Casing type l f <br /> Storage Location Blank Seen <br /> Slot size <br /> Bags cement <br /> _ <br /> GROUTING Buckets bentonite <br /> 17y b5Bags sand/gravel <br /> Depth to wale Filter Pack typesize <br /> Mix Ratios Surge Block: - C y/ n ) <br /> [nstallation Method Discussed with geologist - C y/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />