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MONITORING WELL INST TioN RF-Pok r <br /> T CONSTRUCTION <br /> Date- <br /> Pre mise <br /> ate:Premise Address: l'`lr Total Depth <br /> Screen Length (from) (to) <br /> o.: �'� ' r "+ <br /> Filter Pack (from) (to) <br /> Well N <br /> Bentonite (from) (to) <br /> Inspector. - � - — Grout (from) (Eo) <br /> ns <br /> P Drilling rig type <br /> O.D. I.D. <br /> Permit No. Completion - Stove pipe/christle box (circle one) <br /> Drilling Company: <br /> Casing Z <br /> Driller- -y�� FM <br /> T he_ght <br /> t '`✓`�� <br /> Consultant_ 1 <br /> Geologist X !¢1EFOvE-GRVJND q-SZTy-BOX <br /> t3cvur•�d Suite <br /> SPECIAL.PERMIT INFO. <br /> ' grcLl <br /> Distance to sewer line <br /> Domestic well on site - (y/ n <br /> If yes, location and distance - I }ems <br /> �rrw- w <br /> r Z — » <br /> �s <br /> SAMPLING aacicn <br /> Holding Temperature <br /> Method sxY = <br /> Screening Method <br /> Tracking Sheet - (y/n} — <br /> k <br /> ft, <br /> SPOILS y �, <br /> Storage Method MATERIALS EVELOPMENT <br /> Contamination Noted - {y/ n } Casing type <br /> Storage Location Blank h, Screen K• <br /> Slot size <br /> } GROLTiING �. Bags cement <br /> Buckets bentonite <br /> y Bags sand/gravel <br /> Depth to water ��. Filter Pack type/size <br /> Mix Rados surge Block: - (y/n ) <br /> installation Method !a Discussed with geologist: - (y/ n ) <br /> Quantity Installed - Type•of ncthod <br /> EH 29 29 <br />