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w?lli ��-'�j � <br /> WONITORING WELL INSTALLATION R/E <br /> Date: <br /> CONSTRUCTION <br /> Total Depth 5� <br /> Premise Address: �� 97 �'�" °" / y Screen Length (from) (to) ] - <br /> . Filter Pack (from) 3' (to) — <br /> Well No.: X07 - �p ' Bentonite (from) US (to) 3 <br /> Grout (from) i/3 (to) <br /> Inspector: - Drilling rig type <br /> Auger O.D. S' a- <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: lid N <br /> e�Pa casing <br /> Driller: height <br /> Consultant �' '`' '' �'�"`-`" Dix— —TW-f <br /> Geologist 6( ABOVE-GROUND CHRly-ry_Bpx <br /> COWLEr*N COMPLETION <br /> Ground Suface <br /> SPECIAL PERMIT INFO. <br /> proal <br /> Distance to sewer line �_n <br /> Domestic well on site - n) n <br /> If yes, location and distance /sv <br /> a <br /> aKj Qdotud = $ <br /> SAMPLING 3-f--L/O aec5on _ <br /> Holding Temperature <br /> MethodOF _ <br /> y � R - <br /> Screening Method <br /> Tracking Sheet - (®/ n) - <br /> SPOILS <br /> Storage Method �sS �rw MATERIALS/DEVELOPMENT <br /> Contamination Noted - y/ n) Casing type a 11 V(�- <br /> Storage Location Blank --a-LZ g. Screen �/� ' h• <br /> Slot size <br /> GROUTING Bags cement — <br /> Buckets bentonite <br /> 9 Bags sand/gravel <br /> Depth to water Filter Pack e/size ;d 3 <br /> Mix Ratios 7y�� C4 xo.� ad Surge Block ([yj/ n) <br /> Installation MethoDiscussed with geologist: - n) <br /> Quantity Installed iJ - Type of method AIZ <br /> EH 29 29 leo <br /> I - S �� <br />