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MONITORING WELL INSTALLATION REF, T <br /> Date: G/ l VV d CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) o (to) _ <br /> Well No.: R -�` YC W r� 3� �f` Filter Pack (from) -5 (to)-- j I___ <br /> Bentonite (from} 11 {to) 9.3 <br /> Inspector: i . Grout (from) ,3 (to) 3 <br /> t ��`3 Drilling rig type ,.� Ei ffr"%_ <br /> Permit No. �l �- Auger O.D. , I I. <br /> Completion - Stove pipe/ zri tie box circle one) <br /> Drilling Company: .Z2��� <br /> Driller: casing <br /> height <br /> Consultant1 V 'd <br /> Geologist ..,-"..,.-_.. .' <br /> —OW, <br /> ABOVE-GRCUND Cq-RM Y-BOX <br /> OONF . ION coeaPmcN <br /> SPECIAL PERMIT INFO. Ground Sumacs <br /> Distance to sewer line grout <br /> Domestic well on site - {y/n ) ft. <br /> If yes, location and distance - IL <br /> ft. <br /> v m <br /> M <br /> s` O <br /> C <br /> SAMPLING ilarai <br /> l aecicn w; — <br /> Holding Temperature �J x <br /> Method y ¢"f°+ <br /> pack <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> SPOILS ' <br /> Storage Method �� MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n } 1 r <br /> L <br /> Storage Location Casing type 1 V <br /> BIank� I ft. Screen ft. <br /> $lot size . D <br /> GROUTING Bags cement <br /> Buckets bentonite 1 <br /> Depth to water Bags sand/gravel 1 — y <br /> Mix Ratios Filter Pack type/size MC- -rte <br /> Installation Method Surge Block: - ( y/ ii ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br /> �Ntll) <br />