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MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> CONSTRUCTION <br /> Premise Address: (Auger <br /> ell No. KC�N2r�� L� <br /> k <br /> Inspector: - �f/� otal Depth S' <br /> IM creen Length <br /> H ilter Pack <br /> entonite Pellets L23- Z7- ' <br /> Permit No. rout Z7 - <br /> Consultant G T ompletion-stove pip hris ' <br /> Geologist it }art �/ <br /> �E <br /> IE uger O.D. D y <br /> S I.D. v <br /> SAMPLiNO I+ <br /> Holding Temperature ��G e �_ &**up <br /> Method f. cp ✓� <br /> Screening Method <br /> Tracking Sheet (ylQ ABOVE-GROUND CMiiISIti'-80X <br /> COMPLETION <br /> it COMPLETION <br /> SPOILS Ground Swim <br /> ZZ,i <br /> storage Method v" Si <br /> Contamination Noted - e O ' <br /> Storaa Location 'I1 <br /> �• <br /> ,e <br /> SPECIAL PERMIT INFO. <br /> Distance to sewer lineWaited — r <br /> Domestic well on Bate - yeeA19i5 soon <br /> i If yes$ location &'�distance - = pnvolP&* <br /> II <br /> GROUTING <br /> MATERIALS USED* <br /> Depth to water Casing t v� <br /> Mix Ratios Jp g ype <br /> Installation Method Blank-----.� ft. Screen ft. <br /> Quantity InetalledI Slot size CD Z <br /> Bags cement <br /> Buckets bentonite_ <br /> Bags sand/gravel' <br /> U <br /> Filter Pack type/size- <br /> ,I <br /> 'i <br /> �I <br /> li <br />