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a } <br /> t !i MONITORING WELL INSTALLATION IRE tT .» "f� • . <br /> Date: CONSTRUCTION F c <br /> Premise Address: i �, Total Depth <br /> M' screen Length (from) (to) <br /> Well No.: J. Filter Pack <br /> —t- <br /> Bentonite <br /> fi <br /> Bentonite om) (to) <br /> AA�E <br /> (frm)Inspector: Grout' (to) f <br /> f..'... -. <br /> p,a Drilling rig ty e <br /> Permit No. f v Auger O.D. L.D. <br /> Completion - Stove pipe/chrisie box (c' cl one) <br /> Drilling Company: DV <br /> Driller: I' -0(� O �� « , ' ' casing ; <br /> k/' i.� height <br /> Consultant � �j <br /> Geologist •� � <br /> '0aj AWV4-GROUND 1 <br /> STY-wx <br /> Zo COMPLETION CNRICOMPLEMCN I <br /> SPECIAL PERMIT INFO. f <br /> Grand Surface <br /> r � ff t <br /> W <br /> Q <br /> Distance to sewer4line �� " 32 root ¢ <br /> Domestic well onsite - (Y/ I <br /> ft. <br /> If yes, location and distant '-� " <br /> SAMPLING :lotted : . <br /> ;f aac;ion <br /> Holding Temperature '' -•)I ;: = gravel pack <br /> Method „ C - <br /> Screening Method' 4 <br /> Tracking Sheet �;(y/ n ) <br /> k ft. ft. <br /> r SPOILS 1 . . <br /> Storage Method MATETUALS/DEV'ELOPMENT <br /> Contamination Noted - (y On , • AoW <br /> r Storage Location -, _ � Casing type <br /> Blank2 ft. Screen <br /> Slot size_ <br /> k GROUTING Bags cement <br /> �. Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filtei Pack type/size <br /> Installation Method Surge Block: - ( )(n ) <br /> Quantity Installed` " " w Discussed with eologist: - (Y/ n) <br /> Type of method , <br /> EH 29 29 I <br /> i <br /> v <br /> � JA <br />