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MONITORING WELL INSTALLATION REF-__rCT <br /> S <br /> Date: CON (=ON <br /> t <br /> Premise Address:- F ' %^ '�- �Jrc�� Total Depth F• <br /> ! Screen Length (from) (to) <br /> Well No.: �' `LV Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> inspector. 4 Grout (from) (to) <br /> �� ` / 7 Drilling rig type <br /> Permit No. � L f76G Auger O.D. [.D. <br /> Completion - Stove pipe/cnristie box (circle one) <br /> Drilling Company S`� <br /> Driller. cas ng <br /> FM7 he ghc <br /> IV <br /> Consultan <br /> Geologist AgCyE-„RC(JND <br /> =her'!=T',ON � C�\AAPI <br /> C .iP�.=�CCN <br /> SPECIAL PERMIT INFO. G=nd Suf”' <br /> e <br /> �oc.t <br /> Distance to sewer line 1 <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - 2. <br /> '.J <br /> _ O <br /> s <br /> SAMPLING •�O = a <br /> C ♦ac:cn = <br /> Holding Temperature t _ _ l raCK <br /> Method r'= <br /> Screening Method _ <br /> Tracking Sheet - ( y/ n ) _ <br /> SPOILS L/ <br /> MATERIALS/DEVELOPMENT <br /> Storage Method <br /> Contamination Noted - (y/rd)) U <br /> Storage Location Casing type <br /> Blank ft. Steen —� <br /> Slot size <br /> GROUTING Bags ce7bento <br /> Buckets e <br /> Depth to waterBagssanMix Ratios rj Filter PaizeInstallation Method �^^'� Surge Bly/ nQuantity Installed �� Discusseeologist: - C Y <br /> Type of method - <br /> EH 29 29 <br />