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%,,,,,,MONITORING WELL INSTALLATION RE ,rtT <br /> Dater ► r, I CONS'T'RUCTION <br /> Premise Address-. x.12•�• ( 5" Total Depth <br /> Well No.: <br /> 'AA w Screen Length (from) <br /> Filter Pack (from) Ste( (to) 3 7-- <br /> Inspector. ���Bentonite (from) 3h- (to) 3 <br /> T�� Grout (from) (to) <br /> Drilling rig type <br /> Permit No. °°�v Auger O.D. I.D. <br /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> W�rQ �,y`�[�v� \� <br /> Driller: tN G �-_ casing <br /> height <br /> Consultant_�� <br /> Geologist �bLtr <br /> ABCVE-GRC(JND <br /> 00&VLFr CN Z-Ty-30X <br /> SPECIAL PERMIT NFO, COMPL.EMN <br /> C3rour�C Stsfxs <br /> Distance to sewer 1' a grout <br /> Domestic well on site (y/ n ) <br /> If yes, location and d'sta ce - ft. <br /> SAMPLING = o <br /> •lot:a.� — `c <br /> sacicn <br /> Holding Temperature <br /> Method <br /> Screening Method = <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) - <br /> Storage Location Casing type o fit^ <br /> Blank 3'-( fL Screen 2- R, <br /> GROUTIN,G Slot size <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix•Ratids Bags sand/gravel_ "-At 1Z <br /> Installation Method Filter Pack type/size <br /> Quantity Installed Surge Block: - (y/ ti ) <br /> Discussed with geologist: - ( y/ n) <br /> EH 29 29 Type of method <br />