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Ap I' s <br /> MONITORING WELL.INSTALLATION REF-..KT <br /> Dater/Ci �� CONSTRUCTION <br /> T 7 <br /> ?remise Address: J 2 Total Depth <br /> n,,,",A Screen Length (from) (to) <br /> Well NPw9 /0 �Zi l�� �� I� c l Filter Pack (from) (to} <br /> Bentonite (from) (to) <br /> (nspector-.^ �0 Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. [.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller casing <br /> � he_ght <br /> Consultant �� I <br /> � � <br /> Geologist+ D - ABOVE-GROUND <br /> OX <br /> CCIwFLEMN C OMPLE-MN <br /> CtlMPI=TiCN <br /> SPECIAL PERMIT (NFO. G'nd tae' —7— <br /> i <br /> Distance to sewer line <br /> Domestic well on site - (y/ a) 1 if yes, location and distance - fL <br /> h. <br /> 0 <br /> 3 <br /> SAMPLING slonad e <br /> //� <br /> Holding Tem erasure i = 7 Vq'pack <br /> Method ; <br /> Screening Method 04, r = <br /> Tracking Sheet - n ) =: <br /> L _ = M <br /> SPOILS <br /> Storage Method S MATERIALS/DEVELOP V¢NT <br /> Contamination Noted - (y a) <br /> Storage Location '< Casing type <br /> Blank—fr. Screen ft- <br /> Slot size <br /> GROUTINGBags cern <br /> ent <br /> ' i Buckets bentonite <br /> Depth to water �� k'�� Bags sand/gravei <br /> Mix Ratios Filter Pack typesize <br /> (nstallation Method Surge Block: - C y/ n ) <br /> Quantity Installed Discussed with geologist: - C y/ a) <br /> Type of method <br /> EH 29 29 <br />