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MONITORING WELL INSTALLATIONtT <br /> 3 /2 � <br /> Date: �- CONSTRUCTION <br /> Premise Address: Depth <br /> ' 'l (from) (m) <br /> Well No.: "-f Fd ack (from) (to) <br /> O� tonit (from) (to) <br /> Inspector. Grout (from) b (to) <br /> Dulling rig type C X1 Cr <br /> Permit No. Auger O.D. L I.D. _ <br /> Completion-Stove pipe/christie box (circle one) <br /> Drilling Company: H-� i <br /> Driller. Y f C casinq <br /> height <br /> Consultant fi6t4w 0 <br /> Geologist 074, <br /> OtJND <br /> trPl.l=CION <br /> C <br /> SPECIAL PERMIT INFO. t .j r Qcaud Sulam <br /> Distance to sewer line 23 �' L <br /> Domestic well on site - n) �ttrk fL <br /> If yes, location and dicefL- <br /> ' <br /> r Iff <br /> SAMPLING s{ottad c <br /> Holding Temperature <br /> Method J2 t-Ok S _ <br /> Screening Method 17/%P a.l- tt NQS <br /> Tracking Sheet - (y/ n) _ <br /> — <br /> SPOILS <br /> Storage 1� <br /> Method O y- �asS t C' S""` MA OP <br /> Contamination Noted - y/n) <br /> Storage Location &-A <br /> Blank ft. Screen-= ft. <br /> Slot size <br /> GROUTING 4V6_^ C .� Bags cement <br /> 4epth <br /> S �i(' Buckets bentonite <br /> to water �" 5 Bags sand/gravel <br /> Mix Ratios 21 At +L5% Filter Pack e <br /> Installation Method mow. Surge Bl - - (y/ n) <br /> Quantity Installed Discu with geologist: - (y I n <br /> method <br /> EH 29 29 � S'� ",Y\ U�JoI-�Q:Y <br />