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- MONITORING WELL INSTALLATION REl-•'rl.T <br /> 5 <br /> Date: CONSTRUCTION i <br /> ISO p t c Total Depth <br /> Premise Address: Screen Length (from) (to) 1Z, r <br /> Well No.: Mss Filter Pack (from)_ �yz' <br /> Bentonite (from) <br /> Inspector: <br /> . � Grout (from) d (to) <br /> Dulling rig type , <br /> Permit No. Auger O.D. 1.D. <br /> Completion - Stove pipe/christie bog (circle one) <br /> Drilling Company: !" l <br /> casing <br /> Driller: �7— height- <br /> r <br /> Consultant <br /> Geologist t ABOVE-GRpp , <br /> � COt4PL.ETION CiiFiSSTf-80X COMPLEMN <br /> � y,l:) Ground Surtac� <br /> SPECIAL PERMIT INFO. <br /> sgrout <br /> Distance to sewer line ` 5d-------------- �y,,� 5.t <br /> Domestic well on site - (y/n - <br /> if yes, location and distance �Y2- {�- <br /> ��fi. <br /> Y�R7- r. C <br /> SAMPLING `)�-' slarcod = � <br /> wean = <br /> Holding Temperature zt <br /> Method <br /> Screening Method CT <br /> Tracking Sheet - ( y/ n) <br /> SPOILS f L <br /> Storage Method I , <br /> C?'r 14 S"T ' MA'i'I;RIALS EVELOPMENT <br /> Contamination Noted - (y/�X 7v <br /> Storage Location 3,TCasing type <br /> Blank i Z fr. Screen 2 ft- <br /> Slot size U t o <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water f Bags sand/gravel <br /> Mix Ratios 'p C Filter Pack type/size G:r <br /> Installation Method Surge Block: - n} <br /> ua Nati Installed Discussed with eologist: - (y Xn}t - <br /> Q Type of method �J11t?t <br /> EH 29 29 <br />