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f_ <br /> MONITORING WELL INSTALLATION REF'tWT <br /> 6 9' 0,F 401 <br /> Date: CONSTRUCTION <br /> (�- j <br /> Premise Address: fiKJ V� L �/ ' All � Total Depth q K <br /> Screen Length (from) <br /> Well No.: J Y t V" – �� �� Filter Pack (from) (to) <br /> L Bentonite (from) (to) <br /> Inspector* _\ Y� ��( Grout (from) (to) <br /> Drilling rigtype <br /> Permit No. Ol/ I I aao�(©lAuger O.D. I.D. Ct 2 <br /> �zrF ompletioa -Stove pipe/christie box (circle one) <br /> Drilling Company: ��- - <br /> casing <br /> Driller. S height <br /> IV {' <br /> Consultant ' o I T77 <br /> r �Geologist ✓V_� a-� --- WV- TT <br /> �5i,-r Seib ABOVE-GROUND CHRtSTY_CX <br /> y C^.MP C"Wo -, <br /> SO <br /> ��'� <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line <br /> Domestic well on site - (y/ n' `� <br /> If yes, location and distanceU VfL <br /> 3 <br /> ZZe' t <br /> 320 - <br /> SAMPLING ? I 1 1 sbcud y <br /> J wc"an <br /> Holding Temperature C 36 1,51 = �+�� <br /> Method C e 3C ' 01 — <br /> WC�i'�' Screening Method U tLL <br /> I ` <br /> ETracking Sheet - C y/ n) I � 01. <br /> �Y R. �— <br /> SPOILS <br /> Storage Method MATERIALS/D • .OPMENT� <br /> Contamination Noted - y/ n) 1 C <br /> Storage Location rrtn 5 i'�Q- Casing type V <br /> Blank tl'� ft. Screen O ft. <br /> Slotsize 000 <br /> GROUTING Bags cement <br /> r £ Buckets bentonite �S e <br /> Depth to water <br /> W J Bags sand/gravel , <br /> � Mix Ratios –urq a. (v30�, Jk)Filter Packtype/size <br /> Installation Method Surge Block: -(D/ n ) <br /> Quantity Installed Discussed with geologist: - (Q/n) <br /> Type of method <br />