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MONITORING WELL INSTALLATION R (VT <br /> Z <br /> Date: ..i -3 CONSTILUCTION <br /> Premise Address: Total Depthy <br /> _ Length (gym) <br /> Well No.: Filter Pa (to) <br /> w a rote (hv (to) <br /> TInspector. Grout (from) (to) zf a <br /> . g rig type.466 a <br /> Permit No. �S ger O.D. I.D. <br /> Drilling Company: �o <br /> ompletion -Stove pipe/chrisde box (circle one) <br /> � � � <br /> Driller. r i C 44 casinq <br /> height <br /> Consultant I ��� <br /> Geologist 6J&Jo , -- <br /> A$OVE -BO <br /> Z �Z COwPltiMN CN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line � <br /> Domestic well on site - On) fL <br /> If yes, location and distance - S"i,S M <br /> o ?2 <br /> Holding Temperature = 9raysl <br /> Method C� 5 — <br /> Screening Method R- <br /> Tracking Sheet - (y/n) <br /> A <br /> W M <br /> SPOILS L <br /> Storage Method <br /> A�S�1 c Q .d �p�r`t MATERIALSIDEVELOPNI1:wN'i' <br /> Contamination Noted - n) , <br /> Storage Location__gg✓� S� � <br /> Zen <br /> �� <br /> GROUTING ent <br /> entonite <br /> Depth to water ,c (l �' <br /> Mix Ratios 4- �'0, ize <br /> Installation Method n <br /> Quantity Installed l t: - y <br /> ethod <br /> EH 29 29 �-4. <br /> U` t <br /> a <br /> y -- W -` , -zw 211 3 c y <br />