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MONITORING WELL INSTALLATION R` 'RT <br /> Date: �3 CONSTRUCTION <br /> 4 <br /> Premise Address: C Total Depth 5 <br /> �y Screen Length (from) 6-45" (to) %1 S 4 <br /> Well No.: ��,D Filter Pack (from) LS/ (to) <br /> 412 <br /> Bentonite (from) V (to) 310 <br /> Inspector. % r,z� Grout (from) = (to) <br /> Drilling rig type . -g�/ <br /> Permit No. Auger O.D. e3 <br /> � Completion - Stove pipe/FluisfieTo circle one) <br /> Drilling Company: � LL :!E2 a)i <br /> casin <br /> Driller. � d� t <br /> height <br /> Consultant�/�9, �/b <br /> Geologist <br /> A80VE-GACUND CHffi15T'(-30X <br /> COUP! .=r CN CC&L0t TICN <br /> SPECIAL PERMIT INFO. G=rd Sufact <br /> Distance to sewer line gmtxt <br /> Domestic well on site . ( y / n ) _ F `/', ft. <br /> if yes, location and distance - 2, fL <br /> = o <br /> SAMPLING sbrad <br /> weien <br /> Holding Temper grayst PackMethod ' <br /> Screening Method <br /> Tracking Sheet - Cy / n ) <br /> S_ft. = t tt <br /> SPOILS <br /> Storage Method 04 /y! J MATERIALS/DEVELOPMENT <br /> Contamination Noted - n ) <br /> Storage Location ming type <br /> Blank /) `- Y{✓1 ft screen.l' ft. <br /> Slot size CU <br /> GROUTING Bags cement 0 Gym <br /> Buckets bentonite <br /> Depth to water S^ Bags sand/gravel ;;Vg7 l�YJ <br /> Mix Rados Filter Pack type/size <br /> Installation Method /vim � � z ;c - Surge Block - ( y n ) <br /> Quantity Installed Discussed with geo gist. • ( y / n ) <br /> Type of method <br /> EH 29 29 <br />