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MONITORING WELL INSTALLATION R RT <br /> Date:L I Lck?ll CONSTRUCTION <br /> Premise Address: �{� JC Or� , Total Depth <br /> l�W^� �P w Screen Length (from) (to) <br /> Well No.: 3 Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: lG'""' Grout (from) (to) <br /> C Drilling rig type <br /> Permit Nd GO 3073 Auger O.D. I.D. <br /> fe S r Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: � <br /> Driller: casing <br /> height <br /> Consultant �'G� 17LITA —QV <br /> Geologist /�� L -� T <br /> ABOVE-GRCUND CNRJM-80X <br /> 0O WPLET{ON COMPLETICN <br /> SPECIAL PERMIT INFO. Ground Sumacs <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> ft. <br /> If yes, location and distance - <br /> �. ft. <br /> = m <br /> - C <br /> SAMPLING �loro.i <br /> sadcn <br /> Holding Temperature = gnvlw Pack <br /> Method — <br /> Screenin;Method <br /> Tracking Sheet - ( y/ n ) _ <br /> ft. — ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) I/ <br /> Storage Location Casing ty � <br /> pe ! VU <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/ ii ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />