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- MONITORING WELL INSTALLATION RF ORT <br /> '�j - <br /> r <br /> DateCONS TRU=ON <br /> • ✓, <br /> 7 'j I Total Depth <br /> (to) <br /> Premise Address: Screen Length (from)__/--(94 <br /> Filter Pick (from) (co) <br /> Well No.: Bentonite (from) (to) <br /> Grout (from) (to) <br /> Inspector. {d'l` Drilling rig type <br /> 3 8 Z Auger O.D. I.D. <br /> Permit No. Completion - Stove pine/cluistie box (circle one) <br /> Drilling Company: <br /> �, M��� 'T7 a <br /> � csing <br /> Driller: 7 a_ghC } <br /> Consultant <br /> Geologist A VE-GRCUNO C�RSTY=a7X <br /> M wp LE:Tb N Cp+,'.PL_"TICN <br /> Cxa,nd Sul--ct <br /> MI <br /> SPECIAL PERT INFO. grcx t <br /> Distance to sewer ft. <br /> Domestic well on site .. (y/ n) ft. <br /> If yes, location and distance - <br /> ilar..ai __ C <br /> SAMPLING <br /> _ socicn <br /> Holding Temperature _ t <br /> Method — <br /> r — <br /> Screening Method `t <br /> .j <br /> Tracking Sheet - (y/ n) <br /> SPOILS <br /> MAS ALS/DEVELOPMENT <br /> Storage Method <br /> Contaminadon Noted - (y/ n) Casing type f <br /> Storage Locadon Blank ft- Screen <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravcl <br /> Depth to water Fdter Pack type/size <br /> Mix Ratios Surge Block: - (y/n <br /> installation Method Discussed vAth geologist: - (y/ n <br /> Quantity Installed Type o-f tncdiod <br /> EH 29 29 <br />