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.MONITORING WELL INSTALLATION �-T <br /> PIS _ I Housel r•.a l <br /> rqAC 6 <br /> it Z <br /> 6 y/ <br /> �'1---r-1 <br /> CON_ STR_ UCfI�N <br /> N`"� �DoMCst�rWP.I� <br /> Date: / Tota! Depth g St <br /> S S I n�4 � , <br /> Premise Address: V Screen Length (from) $ 4 1 ' (to) a <br /> 2 Filter Pack (from) S`f, S' (to) <br /> Well No.: ( Bentonite (from) <br /> Grout (from) (LO) <br /> Inspector: Drilling ng tYPe <br /> 0 ► 3 `J Auger OL._ f{ '�--- I.D. 3 e/chrLstie box (circle one) <br /> Permit No. G Completion -Stove pip <br /> l <br /> Drilling Company: <br /> C331^Q <br /> Driller. S' S D <br /> IF717V <br /> ; e 4;nt <br /> Consultant J n <br /> Geologist Z0 k o- AgCVE-GACUNO \' CHRts.Y-Scx <br /> Gjouodsulace <br /> SPECIAL PERMIT INFO. �. US�DO tc L grout <br /> Distance to sewer line T (, R <br /> Domestic well on site - Y n) ft <br /> If yes, location andU g <br /> �W <br /> (\j 5U Tom/ Tfcm/��1w/ <br /> fro <br /> I <br /> m <br /> 1Dol 3 <br /> dottnd �p <br /> s6�gUNG lYion <br /> Holding Tempe ature <br /> Method <br /> Screening Method <br /> Tracking Sheer. - (Y/ n) � <br /> SPOILS <br /> r S lh- MATEMAIS/DEVELOPMENT <br /> Storage Method ebof <br /> Contamination Noted • (Y�fl� S Casing type fr <br /> Storage Location Ec Screen <--- <br /> Slot size 1 <br /> 2D <br /> �I S� W A��r Bags tem 1 b,- <br /> TING Buckets bentonite rr�d c h ns1 <br /> GROU _ <br /> BZ Bags sand/gravel <br /> S Go�rS <br /> Depth to water 4 �h by c� Filtcr Pack type/size i <br /> Mix Ratios d Surge Block - C y <br /> Installation Method Discussed with ge r. ' y/ n) r <br /> QuantityType of method <br /> L <br /> EH 29 29 h <br /> �s�- h�5 ��•< < 6 �� Inti �,�,�;- , ������ .. <br />