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•ONITORING WELL INSTALLATION REI <br /> 5 <br /> Date: <br /> 11`T Aq CONSTRUCTION 5w �'''! �� vW� <br /> $"g <br /> Z_L[ bait �b 35 <br /> 3g 3� z6 39 <br /> Premise Address: �I Total Depth <br /> S / —S o 7 Screen Length (from) (to) <br /> Well No.: W�, �L� V Filter Pack (from) (to) <br /> � W 51A1' �! Bentonite (from) (to) <br /> A,(77 <br /> Inspector: UJ©"�7 �ID 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: ! O� <br /> b) t; <br /> Driller: U W casing <br /> height <br /> Consultant R _Q/A(0 M1 td <br /> Geologist�� <br /> ABOVE-GROUND CHSZ-Y-BOX <br /> / COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. 3S- / Grourd Sumacs <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) �/ /'p�� 67 <br /> If yes, location and distance - !i/ !tom tL <br /> san /n lSVA . � To' � <br /> hit- )-ecaiOWQ _ 66 <br /> SAMPLING �Ql1Gi/1}5 � 61�i1�S �" <br /> Holding Temperature Cr� dl <br /> Method <br /> Screening Method <br /> Tracking Sheet • (y/ n ) yl i a` __ . SAC) <br /> SPOILS4�Id <br /> (7iS�UF�uYS •ti41, b�iS�S. HCl � 07QD� �rIh10 <br /> Storage Method prom /�eQ.MA L P yt <br /> Contamination Noted - (y/ n ) �( yr/I daAk fit/ <br /> Storage Location ` � by r Q lank a ft Screen <br /> .wed ln_l� Wc&kK- <br /> sP L -kc� t� S A k' lot size <br /> TI <br /> GROUNG v t ags cement <br /> ilk uckets bentonite <br /> Depth to water M� 5�" "�� ags sand/gravel <br /> Mix Ratios 1 filter Pack type/size <br /> Installation Method 516 Surge Block: - (y/ n) <br /> Quantity Installed Discussed with geologist: - (y/n) <br /> jy /w- SW- l$1 a of method <br /> EH 29 29 " 9 <br /> 3 <br /> 24C I S'f 6-02 <br /> 3` B330... ! Z l <br /> 5 4 1,54, <br />