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MONITORING WELL INSTALLATION RF T <br /> Date: /Z CONSTRUCTION <br /> Premise Address: cS .,c' Total Depth <br /> ` Screen Length (from} A 1.(to) / <br /> Well No.: All `t Filter Pack (from) 7-S <br /> Bentonite (from) .' �' into) c5 <br /> Inspector: Grout (from)_ _(to) c- <br /> Drilling rig type " <br /> Permit No. Auger O.D. I.D. _ <br /> � // pp , Completion - Stn 4 ,christie bl .,(circle one) <br /> Drilling Company: UJ'Oeu"J _� <br /> sing <br /> Driller: Ut/ <br /> GZ`Y <br /> ,� eight <br /> Consultant �� <br /> Geologist_ T <br /> ABOVE-GROUND <br /> COM?LETION <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ciraund Surf'ct "Z' <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - ( y/(D) ft. <br /> if yes, location and distance - ft. <br /> b <br /> m N <br /> O <br /> SAMPLING & ' slotted c <br /> seclon '_ $ <br /> Holding Temperature — Qravei sack <br /> Method -6c-e_ _ <br /> Screening Method <br /> Tracking Sheet - (D n ) 25 _ <br /> ft — tt. <br /> SPOILS <br /> Storage Method_ MATERIALS/DEVELOPMENT <br /> Contamination Noted - <br /> Storage Location_ cwt 4,� g type <br /> ��� ✓e T <br /> Casin e S� <br /> Blank /b ft. Screen /.S n, <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite a 3 , <br /> Depth to water /S� Bags sand/gravel ' <br /> Mix Ratios /OC> . Filter Pack type/size <br /> Installation Method Surge Block: - CK n ) <br /> Quantity Installed Discussed with geologist: - / n ) <br /> Type of method �'!'` 'e <br />