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MONITORING WELL INSTALLATION REPORT <br /> Date: s - c�s` � � <br /> 6N_S_TRUCTYON <br /> Premise Address:Loci ° � � well No. L4✓ <br /> Inspector: rJ (Total Depth <br /> Gcreen Length_/6, 6 <br /> Filter Pack 116, 15-- -4/1- <br /> Bentonite Pellets ` '7-- <br /> Permit <br /> - <br /> Permit No Z s Grout Z ^ c <br /> Consultant Completio - /christie box <br /> Geologist <br /> I <br /> O.D. <br /> Auger I.D. G <br /> SAMPLING S�Ive 67,5 ------ <br /> Holding Temperature atilt-up <br /> Method <br /> Screening Method <br /> ABOVEGROUND C11RISiY-BOX <br /> Tracking Sheet (y/n) COMPLETION COMPLETION <br /> Ground Sudwe <br /> SPOILS <br /> grout <br /> Storage Method <br /> Contamination Noted - yes/no tt• <br /> Storage Location • <br /> ft. <br /> — 'ra <br /> p <br /> SPECIAL PERMYT INFO. _ <br /> —_ a <br /> Distance to sewer line mon <br /> Domestic well on site - yes/no gm�W pack <br /> If yes, location & distance - <br /> ft. it. <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type <br /> Mix Ratios Blank ft. Screen ft:. <br /> Installation Method Slot size <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> ik - <br />