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MONITORING WELL INSTALLATION Ra,,AT <br /> CONSTRUCTION <br /> Depth <br /> Premise Address: !/ �' 1.11 U _ Total <br /> Screen Length (from) G (to) cJ_ <br /> Well No.: Filter Pack (from) C _(to)� .IN <br /> ee ii Bentonite (from) <br /> Ir: Grout (from) L` <br /> nspecto <br /> Drilling rig typ <br /> Permit No. Auger O.D. I.D. <br /> M Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: -F ra casing— <br /> height <br /> M T <br /> Consultant <br /> �, ♦ I <br /> Geologist ABOVE-GROUND CHRMTY-aOX <br /> OO MPLE71ON COMPLEMN <br /> SPECIAL PERMIT INFO. around Sudace " <br /> groutDistance to sewer line <br /> Domestic well on site - { y n) <br /> If yes, location and distance 4 ft. <br /> w' <br /> 0 <br /> SAMPLING M t10 <br /> s�san _ <br /> Holding Temperature v' = se7iP <br /> Method <br /> Screening Method •' I1n <br /> Tracking Sheet - {y/ n ) !"� <br /> tL <br /> SPOILS L <br /> Storage Method <br /> 0 � 'P1 z [_ MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y On <br /> a Location_ Casing typeStora <br /> Storage Blank ft. Screen 2C1 ft <br /> Slot size )� U <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water /r Bags sand/gravel_ <br /> Mix Ratios 1 b Filter Pack type/lyize <br /> Installation Method ' _ 'r Surge Block: - (y�/ n ) <br /> Quantity Installed Discussed with geologist: - (y/='n); <br /> Type of method -�� <br /> EH 29 29 <br /> r <br />