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MONITORING WELL INSTALLATION RE1;vr(T <br /> Date: ` CONSTRUCTION <br /> ?remise Address: L, Y <br /> 61 <br /> s Total Depth l v <br /> Screen Length (from) (to) <br /> Well No.: O Filter Pack (from) (to) <br /> '^U 1©A 1 Bentonite (from) (to) <br /> Inspectory <br /> . I v 6 Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I-D. <br /> l Completion - Stove pipe/chrisae box (circle one) <br /> Drilling Company' ��o ,�'�' <br /> casLng <br /> Driller. <br /> Consultant <br /> Geologist /�gCyE�;RCt1ND q-Rte'-oOX <br /> Cr"hf?+ctiQN CCVP+`11CN <br /> SPECIAL PERMIT INFO. Ground Suface <br /> 14 <br /> K ' <br /> ?rte <br /> Distance to sewer line <br /> Domestic well on site - C y/ n } - `�- <br /> If yes, location and distance - 47 <br /> - <br /> 3 <br /> a <br /> C <br /> SAMPLING :iocu�d <br /> wcccn J <br /> Holding Temperature = " <br /> Method <br /> Screening Method = _— <br /> Tracking Sheet - C y/ n ) <br /> SPOILS <br /> Storage Method MA's-.RIALS/1)EVELOP?ENT <br /> Contamination Noted - (y/ n) Casing type <br /> Storage Location Blank frScreen fr- <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack typesize <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist. - C y/ n) <br /> Type of method <br /> EH 29 29 9 <br /> C9; <br /> Y V <br />