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MONITORING WELL INSTALLATIONRT <br /> R <br /> Date: /A,Z 07- CONSTRUCTION <br /> S <br /> Premise Address: SX (�,vt/�5 Total. Depth (� <br /> Well No.:-A4W 1Z Screen Length (from) j (to) „L <br /> Filter Pack (from) (2 3 _(to) <br /> (' Bentonite (from) 4i (to) <br /> inspector_. Grout <br /> � (from) - (to) a.r� <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. I.- <br /> Drilling - Stov pipe/cluistie box (circle one <br /> Drilling Company:_�� 'u�--- _ -- ) <br /> Driller:_ casing, <br /> height <br /> Consultant �n <br /> Geologist <br /> A£AVE-GRCUND <br /> CONVL.FT{CN G A SiY30X <br /> SPECIAL PERMIT INFO. COY-P�.DCN <br /> . Crwrj Suiac* <br /> Distance to sewer line <br /> Domestic well on site,- (y/n) <br /> If yes, location and distance - � ft. <br /> — o <br /> SAMPLING tlarod c <br /> tocicn . - -g <br /> Holding Temperature = <br /> Method <br /> Screening Method == _ <br /> Tracking Shcet - (y/ n ) — <br /> �n2 •h tt. — n, <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> StorageLocadon <br /> Casing e� <br /> Blank 2 fr. Screen Z—uft. <br /> Slot size -01 O <br /> GROUTING Bags cement 12- 7 <br /> Euckcts bentonite <br /> Depth to water P Bags sand/gravel ov <br /> MiX Ratios i <br /> Filler Pack type/size Z <br /> dnstallation Method Surge Block: - n ) <br /> Quantity Installed Discussed vAth eologist: - n ) <br /> Type of method�r <br /> EH 29 29. . <br />