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MONITORING WELL INSTTION <br /> �'T. 1270 <br /> $c✓een <br /> / n /�✓ V CONSTRUCTIQN <br /> Date: [ (V �' ycuk /gU —SIU luw�*' <br /> f!8 -//0 fw-4 <br /> `z 9r j I N �(� Total Depth (to) <br /> Premise Address: J Screen Length Cfrom)---(to) <br /> Filter Pack (from) ----r <br /> Well No.: / J 11; 0-/�� Bentonite (from) `7— <br /> A r� l I W ! �F.n Grout (from) <br /> i — <br /> Inspector: iv `t w Drilling rig type K g� <br /> R Dv�O�9 Auger O.D. fes— J.D. �> ' <br /> Permit No. Completion - Stove pipe/ tie box (circle one) <br /> Drilling Company V <br /> rr� ` - �t----i� casing <br /> Driller: <br /> f n "dt-f - (' WUS — I I height <br /> ,� <br /> CORSll1C2n[ C� vet,-/ <br /> l G <br /> Geologist C� <br /> GhFt SiY30X <br /> A��c�55� ree��`r S�pue¢'s +D 4 COMs'CMON �pM?L='T1cN <br /> (ui.:w�^ 2..q„..w(wr f6•e �� �-----CYc�rrj Sl:txY <br /> SPECIAL PERMIT INFO. C(-s„H9 ,N KeSA�)w¢C[ r'/ fry [C(ydtQfwt <br /> Distance to server line �.1t. <br /> Domestic well on site - Cy/ n) <br /> @- <br /> if yes, location and distance - ft. <br /> Iko <br /> pie k op J <br /> SAMPLING socicn = <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Shcet - (Y1 n) /„y <br /> i ft. <br /> g� Gutf ri. <br /> hale: Gi zN J viLi <br /> SPOILS <br /> MATERIALS/DEVEI.OPMENT <br /> Storage Method et C .; Z- r' <br /> Contamination Noted - (y/ n) Casing type <br /> Storage Location <br /> Blank__�—fr Screen—�� <br /> ) Slot size <br /> ) <br /> /�6 j Bags cement <br /> GROUTINGf� Z�( /It fI / Buckets bentonite <br /> r/ Z )13761 of Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Milt Ratios Surge Block: - (Y1 11) <br /> ilutallation Method Discussed vrith geologist. - (y/ n) <br /> Quantity Insta]!ed Type of ncthod <br /> EH 29 29 <br />