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MONITORING WELL INSTALLATION RT 'tT <br /> Date: L % D� CONSTRUCTION <br /> Premise Address) 4F2� Total Depth- <br /> ,�-r Screen Length (from) L? (to) / Z <br /> Well No.: �r�� ,/� r , Filter Pack (from) 2-7 (to)_ to <br /> Bentonite <br /> Inspector: -1�1 !`�,��r-(i� Grout (from) (D lm (too) <br /> Drilling rig type <br /> Permit No. / Au O.D. XI y I.D. <br /> Completi Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: a A"t- �Q as ing 1 <br /> eight \ <br /> Consultant��1�IN`�k <br /> _W <br /> Geologist L L/� -- 7F <br /> ABOVE-GROUND <br /> OOWPLET19P COMCIO IPSTY-800X <br /> SPECIAL PERMIT INFO. Ground Sumacs <br /> Distance to sewer line grout <br /> Domestic well on site - ( y/ n) Z ft <br /> If yes, location and distance - ft <br /> 7-- <br /> SAMPLING <br /> SAMPLING �?S` $10"d <br /> Bacton <br /> Holding Temperaturev&vW= R <br /> acx <br /> Method = <br /> Screening Method <br /> Tracking Sheet - (y/ n ) _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) 1 t,Vic, S nd ,/U <br /> Storage Location Casing type _ 'I` <br /> Blank / Z ft. Screen 15 ft. <br /> Slot size 0.0/0 <br /> GROUTING Bags cement <br /> Buckets bentonites o0 <br /> Depth to water ' E6 S Bags sand/gravel D <br /> Mix Ratios W Cly�-^- Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n <br /> Quantity Installed Discussed with geologist: - (�y/ n ) <br /> Type of method <br /> EH 29 29 <br />