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' � f <br /> MONITORING WELL INSTALLATION REF-.rkT <br /> Date: �J ` CONS'iRUC70N <br /> ?remise Address: �J _arn nr-�� Liv+ Total Depth <br /> Screen Length (from) (to) <br /> Well No.: �t[t�1 D�� F1ter Pack (Erom) (to} <br /> Bentonite (from) (to) <br /> — <br /> inspector: - Grour (Som) (to) <br /> Drilling rig type <br /> Permit No. Auger O D. I.D. <br /> Completion - Stove pipe/caristie box (circle one) <br /> Drilling Company: <br /> Driller. �'n r+ casi zg <br /> — height <br /> Consultant <br /> Geologist C <br /> ,IBCVEvACt.ND C�RiS'`:'-oCX <br /> tvQ!=TCN C--+API i ICN <br /> SPECIAL ?ERMIT INFO. Gewnd Sul"' A <br /> s ' <br /> 9111,Distance to sewer line <br /> Domestic well on site ( y/ n ) �. <br /> if yes, Location and distance <br /> J - _ <br /> 3 <br /> — a <br /> — O <br /> SAMPLING doted — <br /> wccn F*. <br /> — <br /> Holding Temperature <br /> -Method < <br /> Screening Method <br /> Tr Sheet ( y/ n ) _{ <br /> -tL <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOP%ENT <br /> Contamination Noted - (y/ n ) �N PUL <br /> Storage Location Casing type <br /> Blank `7 f- fL Sween C _h- <br /> Slot size � t� <br /> GROUTING Bags cement c <br /> Buckets bentonite c c <br /> Deoth to water D Bags sand/gravel ' IOo <br /> Mix Ratios Filter Pack type/size <br /> [nstallation Method LA DI ...c. Surge Block - (y/ n ) <br /> �� 3 Discussed whiz eologisc - C a) <br /> Quantity Installed j �A� <br /> Type of methodl'Vn n? <br /> EH 29 29 <br />