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MONITORING WELL IN&T-�9N REFWT <br /> Date: �o��0ldoH CONSTRUCTION <br /> /5E-b Gy �/�'u` �t• S Kh/ Total De �0 <br /> Premise Address: th <br /> p <br /> Screen Length (from) (to) <br /> Well NO.:R&w , A411\)-2- , wt.k) Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: �� Grout (from) (to) <br /> �nLOC Drilling rig type <br /> Permit No. �" " Auger O.D. I.D. <br /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> Driller: &05-1 casing <br /> height <br /> Consultant <br /> Geologist (� ,� ,f �► <br /> ABOVE-GROUND <br /> COWPLEfION q{A1SrY 8OX <br /> SPECIAL PERMIT INFO. Ground Surface COMPLETION <br /> Distance to sewer line grout <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - ft. <br /> ft. <br /> ft. <br /> A <br /> m <br /> SAMPLING <br /> a to ttad C <br /> Holding Temperature <br /> Method — Qt's Pack <br /> Screening Method — <br /> Tracking Sheet ( y/ n ) _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted (y <br /> Storage Location rte- S, Casing type ,I PUCi <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water � g b S Bags sand gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation MethoSurge Block: - ( y/ n ) <br /> Quantity Installed A0,>" ( Discussed with geologist: ( y/ n ) <br /> EH 29 29 Type of method <br />