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g ,MONITORING WELL INS'!'AU ATlON R> T , <br /> Date: CONSTRUCTION/ 1 , <br /> Premise Address: l�Z�-� /i 4W O f I aS�'►' p o Total Depth <br /> �,� ,'l 7 Screen Length (from) (to) <br /> Well No.: v Filter Pack (from) 7 5 _ (to) <br /> Bentonite (from)'l So (to) <br /> Inspector. Grout (fro (to) <br /> ing rig <br /> Permit No. 0 �6 I DrillAuger O.D. I.D. <br /> Drilling Company: Completion -Ste i e/christie box (circle one) <br /> Driller. cas ng <br /> 1� height <br /> Consultant A•K <br /> Geologist <br /> AaOV�-GROUND CNAJS7Y-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Strlact COMPLETION <br /> �....���..� <br /> Distance to sewer line � <br /> sl grout <br /> Domestic well on site - (Y/n) 1 t <br /> If Yes,location and distance - n- <br /> ti. R' <br /> SAMPLING <br /> o <br /> Holding Tem G <br /> PaCk <br /> Screening Method <br /> Tracking Sheet /n ) <br /> %- <br /> �r -• YY <br /> �r�fM IM <br /> SPOILS <br /> 70 <br /> Scor e, oil_j 1 MATWaI&DEVELOPhS <br /> Contaloa Noted- (Y/int) ge y�Q�G <br /> S Locationo,. 2 V — ' <br /> Blank 5� ft. Screen Zd ft. <br /> Slot size <br /> GROUTING Bags cement <br /> s.. /��- Buckets bentonite_ = iD0 <br /> Depth to water Bags sand/gravel <br /> Mix Ratios . _ P>7ter Pack typesize i <br /> luiallation Method- <br /> Surge Block: - (y/ ) <br /> Quantity Installed Discussed witheolo <br /> g Sist - �/ n ) <br /> EH 29 29 Type of method <br />