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it <br /> Lj '✓ <br /> i? <br /> I� <br /> MONITORING WELL INSTALLATION REPORT <br /> IIS <br /> Date. CONSTRUCTION <br /> lip <br /> Premise Address:- -_ �L/-�U[��1� Well No. <br /> Inspector: it Total Depth ffO <br /> r , <br /> Screen ]Length 54p` S <br /> Filter Pack SO �3 <br /> I <br /> Bentonite Pellets a3 - Z-Z <br /> Permit Na, ;�,Z 3Z Grout ZZ - <br /> Consultant G T� Completion-Stove pipe Christie boy <br /> Geologist----- <br /> Auger <br /> eologist_ - Auger O.D. l� 7 <br /> Auger I.D., ��y <br /> SAMPLING <br /> Holding Tempera ;ure / <br /> Method <br /> iM � , <br /> Screening Method �� .. <br /> i�. ASOVE-GROUND CHF115YY-box <br /> Tracking. Sheet (y/n) COMPLETION <br /> I� cirouna sut�c. COMPLETION <br /> SPOILS �� <br /> ii grout <br /> Storage Method I <br /> Contamination Note'd - yes/no ; <br /> Storage Location <br /> 'a <br /> is <br /> SPECIAL PERMIT INFO. _ <br /> �0 2C� sioun <br /> Distance to sewer line a.cvon <br /> Domestic well on e'ite _ yes <br /> If yes, location &I distance - '�.' -= P <br /> I� <br /> ip <br /> GROUTING <br /> I? MATERIALS USED, <br /> i <br /> Depth to water � � Casing type_ <br /> rr' Mix Ratios Blank ft. Seen ft. <br /> Installation Method Slot size , <br /> Quantity Installed Bags cement <br /> Buckets bentonite .� <br /> Bags sand/gravel /lam <br /> Filter Pack type/size d cam' 7 <br /> 1 <br /> I <br />