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MONITORJNG wELL INSTALLATION REF-,. , <br /> rZDate: { CU CONS ?,UC 7ON <br /> Premise Address:- rn . Total Depth <br /> ZS <br /> f f n I Screen Length (from)_ (to) - <br /> Well No.: M S <br /> " " 4 �/V 5 Filter Pack (from) � (to) 2 5 <br /> Bentonite (from) (to)---�t <br /> Inspector. Grout (from) 3 (to} 5,,,,^ <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> V1 ` ,�v 5erri 5-31D Completion - Stove pipe/christie box (cirele one) <br /> Drilling Company: V �i LF -30 <br /> Driller. -"� � casi-l� :�ei.glzc 3' <br /> w �S n77 <br /> W— V Consultant '� �� S <br /> Geoiogist t T <br /> ABCVS-GROUND G-Gi1S�IY-30X <br /> C--MP"SCD! <br /> SPECIAL PERMIT INFO. Cvnund Urfa= <br /> Distance to sewer line °Ln <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - <br /> o <br /> 0 <br /> SAMPLING cloned <br /> Holding Temperature r _ 7"panic <br /> MethodF = <br /> Screening Method _ <br /> Tracking Sheet - ( y/ a 1721 <br /> ti. <br /> SPOILS <br /> Storage Method MATERIALSEVELOPMENT <br /> Contamination Noted - / n ) �1 <br /> Storage Location Casing type <br /> BlankfT- Screen_ ZO ft <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> / J Depth to water Bags sand/gravel 1 7 <br /> Mix Ratios Filter Pack typesize ` <br /> installation Method Surge Block: - C Y/ n ) ✓� <br /> ��) l✓ Quantity Installed Discussed with geologist: - C Y/ n) <br /> f/ Type of method <br /> EH 29 29 <br /> 4L SMO, 6-"-& M�" <br /> y r <br />