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J • f • <br /> MONITORING WELL INSTALLATION R U-,e1T <br /> �0. 5. <br /> Date: !yVY, CONSTRUCTION <br /> Premise Address: _�- � �°� Total Depth <br /> S=een Length (from) (to) <br /> Well No.: � �/S �'��2�1 ,,1�.� P�S Filter Pack (from) (to) <br /> Benronite (from) (to) <br /> Inspector. "" `" Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe%christie box (circle one) <br /> Drilling Company: <br /> 7 � <br /> Driller casing <br /> height <br /> Consultant <br /> �� r <br /> Geologist <br /> ABCVE-GROUND <br /> CrW!Fr;CN C}+AtS^!-c'sCX <br /> CCMPL=iIICN <br /> SPECIAL PERMIT INFO. G=nd Sufscs <br /> r � <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) �- <br /> If yes, location and distance - It <br /> 3 <br /> — o <br /> - � o <br /> a <br /> SAMPLING Q <br /> ilottad — a <br /> wccn — <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> 4L ♦ ti. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ ri 1 11 <br /> Storage Location Casing type <br /> Blank fr. Screen h- <br /> Slot size <br /> GROUTING Bags cement <br /> / Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios /l L Filter Pack typesize <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y I a) <br /> Type of method <br /> EH 29 29 <br />