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f <br /> Y- <br /> MONITORING WELL INSTALLATION REF--rLT <br /> v <br /> Date: - CONSTRUCTION <br /> Premise Address:dJ�p �U — l Total Depth 7S� <br /> Screen. Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Grout (from) (to) <br /> Inspector. Drilling rig We <br /> Permit No. Auger O-D. I.D. <br /> Completioo - rove pipe/c"nzistie box (circle one <br /> Drilling Company- <br /> I Ca.s Lag <br /> Driller, lhe;ghc <br /> • T <br /> Consultant_ _ ^ <br /> Geologic N-- <br /> A$CYlr.^uFiCLJN❑ 0-SLS^l-3QX <br /> C^�lvP► 3;ON G-+.iPL- ,CN <br /> SPECIAL PERMIT INFO. G0nd <br /> Distance to sewer line <br /> Domestic well on site - ( y/ a • <br /> If yes, location and distance - - <br /> 73 <br /> SAMPLING (j Z 0Eos <br /> uc-.cn = <br /> Holding Temperature <br /> Method _ <br /> Screening Method = <br /> Tracking Sheet - {y! n ) <br /> ���;ti ♦ w = !t. <br /> SPOILS <br /> Storage Method M`'`TERIALS/DEVELOPN ENT <br /> Contamination Noted - (y/ n) Casing type <br /> Storage Location Blank f- Screen ft- <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentoni e <br /> Depth to water IS Bags sand/gra <br /> M :—:: <br /> ix Ratios Filter Pack typ size <br /> Installation Method Surge Bloch•. (y/ n ) <br /> Quantity Installed Discussed geologist- - C y/ a) <br /> Type of the od <br /> EH 29 29 <br />