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`,010NITORING WELL INSTALLATION RM%4 <br /> Date-_ . ... O�ISTRUCTION <br /> Premise Address• S- a Total Depth 7G fly. <br /> en Ungth (from) <br /> Well No.;0 ! U b� ^- Facet Pack (from) !0 (to) <br /> Bentonite (from), 39 (to) <br /> Inspector. Grout (from) (to) <br /> t� Drilling rig type <br /> Permit No. Auger O.D, I.D. <br /> ' Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller casl.nq <br /> height <br /> Consultant �•�� <br /> w <br /> Geologist ., <br /> ABOVE-GROUND CHRtM4 <br /> COUPLE=" COMPLETON <br /> SPECIAL PERMIT INFO Om"$Wf&= <br /> Distance to sewer line � grCOA <br /> Domestic well on site- /n) �. 2 � » <br /> If yes, location and distance- 3 <br /> Sr a <br /> Holding TeMpera <br /> Method <br /> Screening Method <br /> Tracking Sheet -On) , <br /> ,.tt. <br /> SPOILS <br /> Storage Method MATERIALS/DEW L0PMENT <br /> Contamination Noted- n <br /> Storage Location Casing type �•" 1CJ -- <br /> Blank qe ft. Screen d ft. <br /> Slot size v <br /> C;BOUTINg Bags cement 2. <br /> Buckets bentonite 5' <br /> Depth to meter ql) Bags sand/gravel <br /> Mix Ratios Filter Pack typesize <br /> Installation Method Surge Block: <br /> Discussed with geo ogist: - spy n) <br /> Quantity Installed � <br /> Type of method <br /> EH 29 29 <br />