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0 MONITORING WELL INSTALLATION 16ORT <br />Date: / <br />Premise Address:z0d- <br />Well No.: MW -� <br />Inspector:_ <br />Permit No. �C3Gr 7a 0 <br />Drilling Company: 1 &'U6dukk <br />Driller: /w 04 <br />Consultant S� i�c-55 <br />Geologist S✓I& /S'941-. Zq <br />SPECIAL PERMIT INFO. <br />Distance to sewer line <br />Domestic well on site - ( y / <br />If yes, location and distance <br />SAMPLING <br />Holding Temperature <br />Method <br />Screening Method <br />Tracking Sheet - ( y/ ) <br />SPOILS <br />Storage Method <br />Contamination Noted - ( y / n ) <br />CONSTRUCTION <br />Total Depth So <br />Screen Length (from)' Z (to)SM <br />Filtet Pack (from) --71 (to)<,g) <br />Bentonite' (from) C-1 (to) 2 <br />Grout (from) / Kto) <br />Drilling rig type 1-fewosu S,TLe- o•7 c 6x4? <br />Auger O.D. g I.D. <br />11 <br />Completion - Stove pipe/chnstie box (circle one) <br />casing <br />height <br />ABOVE -GROUND <br />COWPLE CN <br />G#�FI157Y-B.OX <br />ON <br />C33 ovnd Surtxs <br />grout <br />2 3 ft. <br />_eft. <br />— o <br />s4caon — <br />MATERIALS/DEVELOPMENT <br />Storage Location <br />Casing type <br />- - <br />Blank 2S ft. Screen <br />Slot size 2d <br />GROUTING <br />Bags cement <br />i <br />Buckets bentonite_ 3 Z <br />Depth to water 3s <br />Bags sand/gravel / 3 <br />Mix Ratios <br />Filter Pack type/size <br />Installation Method <br />___. Surge_B1ock:_(.y_/_n_) UO <br />Quantity Installed <br />Discussed with geologist: - (y/Qi-? <br />Type of method i <br />EH 29 29 <br />