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MONITORING WELL INSTALLATION REF-, +%r <br /> Date:, �� I / CONSTRUCTION r <br /> r f �5 <br /> Premise Address: ,d {S Total Depth ll Q f✓ d <br /> Screen Length (Crows) (to} <br /> Well No.: Filter Pack (from) (to) <br /> � ) Bentonite (from) (to) <br /> ,nspector: ��� '`� Grout (from) {to} <br /> Z Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> / �v Completion -Stove pipe/christie bog (circle one) <br /> Drilling Company-— +� -,,,, Q <br /> Driller. �✓ 1S � ��/�/�"`"� casing <br /> ��� Lasing <br /> Consultant '� 7 <br /> 4 T <br /> Geologist C) L t S <br /> ABOVE-GROUND CHRlS"TYA X <br /> CC14Ft_'--MN CO(y,�pi - ,CN <br /> SPECIAL PERMIT INFO. G°"r <br /> Distance to sewer line <br /> Domestic well on site - ( Y r C9 kw-Af It. <br /> if yes, location and distance - <br /> /Sta,Y K' — <br /> Q]cc�v rim; ((0. — <br /> SAMPUNG <br /> Holding Temperature ^n 72+d Facp. <br /> 07 <br /> Method M� CY <br /> Screening Method_ 1 T Awa C �i d 0 <br /> Tracking Sheet - ( y/ a } <br /> _n- <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n) <br /> CasinStorage Location Blank type <br /> Blank_ _ �ft. Screen fr- <br /> Slot size <br /> GROUTING Bags cement <br /> J n. Buckets bentonite / <br /> Depth to water [ Bags sand/gravel <br /> Mix Ratios Fater Pack ' e <br /> Installation Method Surge Stock: y/ n ) <br /> Quantity Installed Discvsse 'th geologist-- - ( y/n} <br /> Type o ethod <br /> EH 29 29 n <br />