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MONITORING WELL INSTALLATION Rlar-&T <br /> 3 O <br /> Date: pO CONSTRUCTION �� <br /> premise Address: I V�' YJd� `i p Total Depth <br /> e -'Screen Length (from) (to) <br /> Well No.: M �/ _ 10 ? ' Filter pack (from) 3 (to) y' I' <br /> w© . <br /> b- Bentonite (from)— <br /> \A) IBJ 9 I ,q Grout (Som) '' <br /> Drilling rig type <br /> Permit No. SM Auger O.D. I•D <br /> 30 y 6 4 Completion - Stove pipe/chrisae box (circle one) <br /> Drilling Company: Qa'0 <br /> (/ C33i.1CJ <br /> Driller. ' height <br /> Consultant 29 <br /> Geologist. 0 1�3 /lBCYE.3ACUND C7-A15"!oOX <br /> 6 -'p CCf Q RCN C {pl=iiCN <br /> SPECIAL PERMIT INFO. <br /> �f 4,0 r <br /> n� <br /> Distance to sewer lineI <br /> Domestic well on site - ( y/ n ) t <br /> if yes, location and distance - d <br /> /5 S a <br /> 'oV+Si IR�111 � o <br /> 2�� ibRad = `a <br /> SAMPLING ween <br /> Holding Temperature <br /> Method <br /> Screening Method = <br /> Tracking Sheer - C y/ n ) <br /> 7 n- <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (Y n ) <br /> CasinStorage Location Blank type <br /> Blank ft Screen <br /> D l _ �/ Slot size <br /> GROUTING /,0 tlO Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water <br /> Fater Pack type/size <br /> Mix Ratios <br /> Installation Method Surge Block: - (Y/ n ) <br /> Quantity Installed Discussed with geologist - C Y <br /> Type of method <br /> EH 29 29 0. -c,Y�. nn <br /> tJ <br />