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•ONITORING WELL INSTALLATION REi-.�1F' <br /> J s�tl SWIS sw <br /> Date: /Z'/R CONSTRUCTION 1 <br /> Premise Address: L( (lwv �iMtP� Total Depth 0 <br /> Screen Length (from) (to) <br /> Well No.: 5W -1� 5W -f5 1 S�— Filter Pack (from)—(to)— <br /> Bentonite <br /> from) (to)Bentonite (from) (to) <br /> Inspector: Grout (from)-(to)— <br /> Drilling <br /> from) (to)Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> n n Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: r✓l h/ <br /> Driller: �, (Xd (� casing <br /> height <br /> Consultant <br /> Geologist <br /> A80UNO <br /> COMPI+ CHRZ7Y-80X <br /> Y( FLErIeT1ON <br /> CCMPL°TICN <br /> SPECIAL PERMIT INFO. Ground Sunan <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) ft <br /> If yes, location and distance - ft <br /> fD <br /> jWq eF3' Ur�kr <br /> SAMPLING Sw'S 3d dottad = c <br /> station <br /> Holding Temperaturegravel Pack <br /> Su <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) _ <br /> n <br /> SPOILS <br /> Storage Method „ MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location `4 Casing type <br /> Blank ft. Screen ft. <br /> '1 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 /> Type of method <br /> EH 29 29 <br />