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MONITORING WELL INSTALLATION 1L ORT <br /> Date : (�/� z � 6Y fel tOP CONSTRUCTION <br /> Premise Address: ?6 06 //L r� ry � ,� Total Depth ct . S <br />.I Screen Length (from) (to) <br /> Well No. : z , c I i � L '7 �c R � c � ' c Filter Pack <br /> 1. �� 1 (from) tF SZ (to)_ _ <br /> Bentonite (from) /4 (to)" 1 <br /> Inspector: �1� Grout (fro (to) c ,_z_ <br /> Drilling rig e <br /> Permit No. Auger O.D. 1.Do , %a <br /> cit <br /> - Stove pipe/christie box (circle one) <br /> Drilling Company: ( lt S C c <br /> Driller: <br /> casing <br /> height <br /> Consultant � �i.r-�c <br /> Geologist <br /> ABOVE=GROUND <br /> COMPLETION CHAISI7-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO, Ground Surface <br /> 8 5 rrZ( •, <br /> Distance to sewer line grout <br /> Domestic well on site - ( y / n , 5i <br /> If yes, location and distance - -i =— ft• <br /> 41qtt. <br /> it = <br /> SAMPLING slotted — <br /> tec8on — <br /> Holding Temperature <br /> Method — V"V64 Pack <br /> Screening Method <br /> Tracking Sheet - ( y / n ) <br /> no <br /> no <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y / n ) <br /> Storage Location Casing type )/ L <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y / n ) <br /> Quantity Installed Discussed with geologist: - ( y / n ) <br /> EH 29 29 Type of method <br />