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f MONITORING WELL <br /> R <br /> LTION" <br /> EP. r(T <br /> n -� <br /> 6vif� 77. QV� CONSTRUCTION <br /> Date:_ <br /> Total Depth�� j <br /> ?remise Address: L Sceea Length (from) -3,!2 <br /> (to) <br /> IIA1 'l (� 3 AM W Filter Pack (from) 3 3 (to) C� <br /> 4\'ell No.: I y 4�Bentonite (from) 3 i (to) 33 <br /> � y _ out (from) S u�=(to) 3 ! <br /> Inspector: rilling rig type <br /> ger <br /> Permit No. 0 ,` mpletion - Stove pipe/cbrisae box (circle one) {I <br /> Drilling Company: J <br /> casing <br /> Driller- <br /> Consultant <br /> riller Consultant <br /> Ue - <br /> Geologis[ ABCVE.;RCUNO <br /> rCOAdptz-rCN'. <br /> G=nd <br /> SPECIAL PERMIT INFO- 71 v — it + <br /> Distance to sewer line <br /> Domestic well on site - ( Y/ n ) w3 J L <br /> Ifs, location and d---ance 4�.. <br /> abttad � `a <br /> SAMPLING <br /> o g Temperature �X Y <br /> Method <br /> Screening Method <br /> tracking Sheet C Y/ n) ��S� 2iln <br /> ' SPOILS f�( S `! <br /> tL _ MATERIAIS/DEVELOPNTNT t I <br /> r Storage Method ( 2 <br /> Contamination IN - (Y/ n) X-using type f <br /> Sa een — <br /> -Storage Location Bl fL <br /> K '� � j 3 —7 � � Slot size <br /> uv Bags cement <br /> GROUTING �S{ r 0 (�,uy(/S Buckets bentonite <br /> „1 Bags <br /> sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Ratios <br /> Surge Block: - C y/ n ) ": <br /> Installation Method Discussed with geologist: - ( Y <br /> Quantity Installed Type of•metho <br /> lel <br /> FH 29 29 - <br /> � � 4Y - <br />