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'ONITORING WELL I <br /> IT � <br /> � Date: <br /> CONS'T'RUCTION � <br /> Premise Address: yf/i�1 <br /> Total (Depth <br /> J Screen Length (from) (to) <br /> Well <br /> Filter iPack ;„ (from) (to) � <br /> No.: "" >w z_R.. _ � y.' '.Bentonite (from) (to) <br /> Inspector: <br /> - Groutiw (from) Z5 (to) O <br /> l <br /> .` Drilling rig type - <br /> Permit No. �' Z� I'O.Dr_�ii(Z.r <br /> _ � T- AugerLD. <br /> -Comp l'etioii=Stove pipe%chxistie boxti'(circle one) <br /> Drilling Company: , <br /> E + �'r -+•°�•1 Its.t k • �F '� ,. �-��, S` � "X C, .I�..:.s• �'.�� q,�+ -b. ,A .� y , <br />_4. Driller. i, ;I casing <br /> height Y <br /> � • ,:,, ` .z},. 1,.1'•u .-� `:S: •I`.� r �.y. 1;4 �. 's ! �I X�fr' � �. � r _ ,! <br />{ Consultant <br /> GeologistA9 <br /> ��•�-l�,�S f <br /> QYE-GROIJNQ <br /> CO[ t��CION y CHRISTY-80X <br /> V `` ACOMPLN 4 <br /> SPECIAL PERM t JNFO. Gtnur�d Surtsca� <br /> EM <br /> grout ' 3 <br /> Distance to se' r line ' �,.ht <br /> Domestic well o ire (y'/ n) ' ft. # <br /> If yes, location an' istance <br /> 78 <br /> ".'SAMPLINGan �C a <br /> . :: <br /> .Holding Temperature `, `+ a ' 'i . 4° • All grsval Pack <br /> Method =: <br /> I, n3 . <br /> Screening Method - r — <br /> Tracking Sheet - (y/ n ) 4 <br /> IISI <br /> SPOILS r '��f`<_ '.Yr_- ` ,`„ `� v ,-'••+• yayr.�` *`� 1` i ' •' ,`r S t �. _L ,.. .. F <br /> Storage Meth rd %V -� `' MATERIALS/D�EVEI;OPMENT <br /> Contamination oted (y/ n x . <br /> Storage Location + �. r���.. _��� t Casing type <br /> N <br /> Blank J it ft. Screen ft. <br /> Slot sizea�. s <br /> GROUTING i <br /> Bags cement ' <br /> Buckets bentonite <br /> Depth to water �T - �-- Bags sand/gravel <br /> Mix Ratios �' Filter Pack type/size <br /> Installation Method Surge'Block: .y/ n) <br /> •Quantity installed �DQe .� . , 'Discussed wirli'geologist: - (y/ n') ' <br /> I ,, n Type oF;�method <br />