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tl- MONITORING WELL INSTALLATION RE!- T w <br /> Date: Co ' ( T 1- CONSTRUCTION <br /> Premise Address:- ZqO-L ` __ Total Depth <br /> n Screen Length (from) (to) <br /> Well No.: 1 w 1 W J jM(A) Filter Pack (from) (to) 2 <br /> Bentonite (from) (to) ZD , <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: ��1�'�-�k (�R i <br /> Driller: PZ tn - - SGC casing <br /> 1 r '_ _ r height <br /> L <br /> Consultant ua t�C�L��+ T <br /> M T <br /> 7 M <br /> Geologist VLSA •- <br /> T <br /> ,1. - I` ���f/� ABOVE-GROUND CHRMTY-SOX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. M MWa �s� <br /> VZ <br /> grow <br /> Distance to sewer line <br /> Domestic well on site - / n ) l0 `�} std 2 <br /> if yes, location and distance - su+- R• <br /> ft. <br /> � <br /> M W ilo �Vy v5 i Zr, <br /> s <br /> SAMPLING r •lotted <br /> 5 cV% wcxon <br /> Holding Temperature '` C� ':- _ graysl pack '- <br /> Method <br /> Screening Method n <br /> Tracking Sheet - (V n U"►, Lbw45 <br /> SPOILS <br /> Storage Method bi(� t�S�lG MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y n Z1 r P G �� <br /> Storage Location �� Casing type <br /> Blank ft. Screen 20 h. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonitej ba '511,e- ChI25 <br /> Depth to water 3� " �l Bags sand/gravel e <br /> Mix Ratios + X54 l IN Filter Pack type/size <br /> Installation Metho ou ! Surge Block: - (y/ n <br /> Quantity Installed Discussed with geo gist: - y n } <br /> r <br /> Q ty <br /> Type of method <br /> EH 29 29 <br /> MW5 <br /> r <br />