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•MONITORING WELL INSTALLATION IT <br /> Date: C0wn <br /> �� // /J CONSTRUCTION <br /> Premise Address: �O- WvtrC�(,�,4p rY�/ <br /> /" a ' D(� Total Depth <br /> Well No.: "'^V Screen Length (from)�_(to) <br /> Filter Pack (from) <br /> [�^^o tom( Bentonite ----(to) <br /> Inspector. (from) (ro)�_ <br /> Grout (from)___(to)�_ <br /> Permit No. .Drilling rig type <br /> Auger OD._. I.D. <br /> Drilling Company: Complcdon - Stove pipe/cliristie box (c— u�— <br /> Driller: ri`--M <br /> casing <br /> Consultant_ K� � _ 1 � height <br /> V 'q <br /> Geologist <br /> �avEcacurrD I\\ <br /> �hVLFDON G A Siy 3p <br /> SPECIAL PERMIT INFO. <br /> Cirwrd Sts(xe <br /> Distance to sewer line <br /> Domestic well on site.- (Y/n) ora <br /> If yes, location and distance - � <br /> ' ft. <br /> SAMPLING — .. <br /> _ a <br /> darai c <br /> Holding Temperature tocicn = <br /> Method <br /> Screening Method <br /> Tracking Sheet - (Y/ n ) 7 <br /> SPOILS <br /> i A$U <br /> Storage Method MATERIALS/DEVE[OPMENT <br /> ContMInadon Nored • (y/n) - <br /> Storage Location g tYP 2f/px <br /> Casing e <br /> Blank�� fi Screen__j.0 ft. <br /> GROUTING Slot size 0.cid <br /> Bags cement_ ' 9 . <br /> Depth to water Buckets bentonite 75 <br /> Miz Ratios Bags sand/gravel_, z f0 <br /> -Installation Method Filter Pack type/size n Z <br /> Quantity Installed Surge Block: - QlY1/ tl ) <br /> Discussed vrith ologist: - (�} /n ) <br /> EH 29 29. Type of nctliod <br />