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� l <br /> MONITORING wFu INSTALLATION REl' <br /> Z/1 Al to � <br /> Date: <br /> CONSTRUCTION <br /> Premise Addres� J �. � Total Depth O <br /> Screen Length (from) `7 -(to) b't <br /> Well No.: 1 `" 'Z Filter Pack (from) (to)t'T <br /> � -- <br /> ;/ n I� Bentonite (from) -L� {to) Y <br /> Inspector: �JW�V _ Grout (from) (to)„ 9Z <br /> / Drilling rig type D S <br /> Permit No! Auger O.D. I.D. `-f`, <br /> ` �.[ Completion - Stove pipe/christie bog (circle ane) <br /> Drilling�ompany: � �_) ._ <br /> Driller: J casing �— <br /> height <br /> i ( <br /> Consultan <br /> Geologist Ajpy -GROUNO <br /> COMpLEf10N CHRZTY-8OX <br /> COMPLEnCN <br /> SPECIAL PERMIT INFO. t3=nd Surface <br /> �� 1 <br /> Distance to sewer linegrout, <br /> Domestic well on site - (y n) �� tt. <br /> If yes, location and distance - b fL ll <br /> e <br /> _3n N <br /> V r •'V � <br /> r+� m <br /> b <br /> O <br /> SAMPLING siattod ;; c <br /> sac�on �•- <br /> Holding Temperature C" _ _ 9MV1+Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n} 'A <br /> SPOILS <br /> Storage Method '"" MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n') r? PUC <br /> Storage Location 7� 3 l"u Casing type <br /> Blank ls� ft. Screen ZO ft. <br /> Slot size ZO <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to waterBags sand/gravel " o S <br /> Mix Ratios _ 2q" f Filter Pack type/size � " � '^ <br /> Installation Method 2- Surge Block: - yy/ n} <br /> Quantity Installed Discussed widi. ologist: - y/ i) <br /> Type of method <br /> EH 29 29 <br />