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MONITORING WELL INSTALLATION REAr <br /> Date: 1 �✓ /` o <br /> c r'� < CONSTRUCTION <br /> Premise Address: l W 4 JT6pjj66(JL Total Depth <br /> MW i 1 '3 Screen Length (from)_��(to) `l0 <br /> Well No.: v�/ Filter Pack (from) (to) go, <br /> Bentonite (from) (to) <br /> Inspector: J(D�r �6N� Grout (from) (to) <br /> 3 I Drilling rig type 72, � — <br /> Permit No. Auger O.D. I.D. <br /> S Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: S casing <br /> height <br /> Consultant •A, T <br /> Geologist <br /> ABOVE-GROUND <br /> COMPLETION CHR*7Y-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surfeoe <br /> Distance to sewer line grout <br /> Domestic well on site / n) <br /> If yes, location and dis ce - <br /> IM <br /> w = m <br /> r <br /> C <br /> SAMPLING slotted <br /> 1'a secdon <br /> Holding Temperature _ gravel Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> b tt. F = tt. <br /> SPOILS <br /> Storage Method � ^ MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING p_ YJ Bags cement <br /> gG — 0 \ ��Z, Buckets bentonite <br /> Depth to water J 0 Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method A Y LAVAL4 Surge Block: - (y/ n) <br /> Quantity Installed Discussed with geologist: - (y/- n) <br /> Type of method <br /> EH 29 29 <br />