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r� 1� <br /> MONITORING WELL INSTALLATION Ra,&T <br /> 6 <br /> Date: /O �E?SZ I l�� (�✓e rcY{ 'i <br /> Premise Address: x Q j`�t ry Total Depth v <br /> Screen Length (from) (to) <br /> Well No.: V Filter Pack (from)-(to)- <br /> Bentonite <br /> from) (to)Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> 1 Drilling rig typeM <br /> Permit No. v Auger O-D- /()�_ I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller. L_ height <br /> Consultant � ��,,� Ti <br /> Geologist ov Vw <br /> ABOVE-GACUND <br /> Crb1PLET'AN CMN <br /> SPECIAL PERMIT INFO. S SC "Q� Ckou+d Sulacs <br /> Distance to sewer line wow <br /> Domestic well on site - ( y/ n ) F <br /> If yes, location and distance - I _ 1 <br /> ft. _ <br /> a <br /> SAMPLING Rnd _ 3 <br /> .on <br /> Ho ' g Temperature �\ ?: _ P <br /> Metho 11 V <br /> Scree ethod <br /> Tra g She ( yl n) <br /> fog iS Covk-rd KV i< <br /> SPOILS sal d fo r�dz a un f p a-4&0, <br /> �i U t3 <br /> LS t�MO�%QeQ 9� Aak s ryea <br /> Storage Method U l. �'' MATERIALS/DEVELOPMENT <br /> � W <br /> Contamination Noted - C y/� / i t �V C <br /> Storage Location Casing type '-j <br /> Blank ft SQeen fL <br /> Slot size <br /> GROUTING ` Bags cement <br /> / Buckets bentonite <br /> Depth to water / v � / Bags sand/gravel <br /> Mix Ratios l Filter Pack type/size <br /> Installation Method J Surge Block: - (y/n ) <br /> Quantity Installed Discussed with geologist - (y/ a) <br /> Type/of method I, I <br /> EH 29 29 fW l-e /rGLV� U / P'fQ r rlYdm �t l vt�I y P� v�CS cR�! <br />