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MONITORING WELL INSTALLATION REF`/f <br /> Date: L� / �� <br /> CONSTRUCTION <br /> ` l� a <br /> Premise Address: / � 5'f' "e7 � � Total Depth <br /> M4 /k / Screen Length (from) t (to) 6 <br /> Well No.: 4� Filter Pack (from) ([o) <br /> iA�/LL / Bentonite (from) (to) <br /> Inspector. �'j l�.� B-Q�1 Grout (from). h (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> 1 , Completion - Stove pipe/christie box (circle one) <br /> Drilling Company:. . f <br /> Driller: casing <br /> 77: <br /> height <br /> Consul ant M <br /> Geologist T <br /> ABOVr:-GRCLIND <br /> COMPLETION CF4iWN-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground` 2 Ground S++t� —rte <br /> Distance to sewer line___ JCA, " grout <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - '�'-�^—'tt- <br /> ft. <br /> lyd: h <br /> SAMPLING ?�" /i,.Z. <br /> slonad <br /> Holding Temperature <br /> Method gra Pack <br /> Screening Method F#b <br /> Tracking Sheet - (y/ n ) <br /> SPOILS 7 <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) rjDb- <br /> Storage Location Casing e <br /> Blank` (eft. Screen 'Grb ft. <br /> Slot size 0, <br /> GROUTING Bags cement <br /> Buckets bentonite "7 <br /> Depth to water -� Bags sand/gravel <br /> Mix Ratios_/n_ /_ Filter Pack type/size 'Ji-112— <br /> installation Method Surge Block: - DY n ) <br /> Quantity Installed Discussed witPtgeologist•.Co/ n ) <br /> Type of method <br /> EH 29 29 <br />