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MONITORING WELL INSTALLATION REI-. LT <br /> Date: ��tl� CONSTRUCTION <br /> Premise Address: d2S C Total Depth <br /> r Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Benronice (from) (to) <br /> Inspector. Grour (from)—(to)- <br /> Drilling <br /> from) (to)Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: <br /> s � Completion -Stove pipe/christie box (circle one) <br /> Driller. cas ing <br /> he'_ghc <br /> Consultant <br /> Geologist <br /> ASCVE-GAOUND CNAISTY-3CX <br /> CrFAL_R'ICN CCMPLcTiCN <br /> SPECIAL PERMIT INFO. G=nd SOC' T� <br /> Distance to sewer line Iny�� . 70n <br /> Domestic well on site - ( y/ n ) 3 <br /> (f yes, location and distance - <br /> } a <br /> SAMPLING Gt 1 {IQRpd <br /> Holding Temp e = 72ys';--X <br /> Method <br /> Screening Mepfiod = <br /> Tracking Sh9 t - C y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination No d - (y/ n) <br /> Storage Location Casing type <br /> Blank fr. Screen <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios /vi e — Filter Pack type/size <br /> Installation Me rh Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologisr: - ( y/ a) <br /> Type of method <br /> EH 29 29 <br />