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MONITORING WELL INSTALLATION RETORT <br /> Date: !i o s� CONSTRUCTION <br /> Premise Address: 3o Total Depth b 5 <br /> Screen Length (from) '�-O (to) <br /> � — <br /> Well No.: rA(,t/-l-L + /-I ?, Filter Pack (from) `I'er (to) 6 <br /> Bentonite (from) (to) tl X <br /> Inspector: QJ-A I ,-el Grout (from) <br /> Drilling rig type <br /> Permit No. !�3 (0) Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller:_ :�220 LIt casing <br /> height <br /> Consultant (soar C' moo31A <br /> Geologist _ 0 v <br /> ABOVE-G R CUND Ir <br /> COMPLETION CNAISTY-Sox <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surfws <br /> Distance to sewer I jge Ofout <br /> Domestic well site - (y/ n ) ft. <br /> If yes, to on and distance - <br /> = m <br /> O <br /> C <br /> SAMPLING = ° <br /> dotted — d <br /> aacaon — <br /> Holding Temperature can L r'z <br /> Pack <br /> Method E'' v" <br /> vo <br /> Screening Method <br /> Tracking Sheety n) — <br /> // <br /> SPOILS <br /> Storage Method5 5 1��.� _MATERIALS/DEVELOPMENT <br /> Contamination Noted - <br /> Storage Location rn s r f., YAW A c K / Casing type 2,,J Blank .5-U ft. Screen <br /> Slot size . y Lo <br /> GROUTING Bags cement <br /> Buckets bentonite / <br /> Depth to water .ti Bags sand/gravel <br /> Mix Ratios6 c Filter Pack type/size <br /> Installation Meth d� �sQ JC --K. ,,�_,,, Surge Block: - (y n)) <br /> Quantity Installed Discussed with geo ogist: - (y 4) <br /> Type of method <br /> EH 29 29 <br />