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MONITORING WELL INSTALLA'T'ION REF,KT <br /> I Z b2 �l I.V07 CONSTRUCTION <br /> Date: <br /> Total Depth <br /> Premise Address: S=een Length (from) (to) <br /> Filter Pack (from) (to)_Well No.: \ Bentonite (from) (to) <br /> C �� Grout (from) (to) <br /> (nspector. Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. C Complerion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> cas i.:zg <br /> Driller. a height <br /> Consultant. <br /> w <br /> Geologist JIBCYE-.3RCUN0 �Z-1-11-acX <br /> Its!°'CION CPL i,CN <br /> CSOW4 G=rld SU12Cs <br /> SPECIAL PERMIT INFO. Jr /Z <br /> Distance to sewer line I �- <br /> Domestic well on site - (y/ n ) 17 Z 3 if yes, location and distance - L <br /> a <br /> Islo tad -- a <br /> SAMPLING �«i��4-F� <br /> wc°cn <br /> 7,VW Pack <br /> Holding Temperature S '- <br /> Method ~' <br /> Screening Method <br /> C 3/ <br /> Tracking Sheet - C y/ n) n <br /> 1 <br /> SPOILS <br /> Storage Method MgT�ALS/0E0P <br /> VELNIENT <br /> Contaminarion Noted - (y/ n) '�g� Casing type <br /> Storage Location Blank ft. S=een---.ft- <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/ n ) <br /> Installation Method Discussed with geologist: - ( Y/ n) <br /> Quantity Installed Type of m od <br /> F_H 29 29 <br /> 1 <br />