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MONITORING WELL INSTALLATION REPORT <br /> 1 f i1 , <br /> Date : 1 CONSTRUCTION � u/�-"�C/Jn <br /> Premise Addr ss : a awjJJ4Waq 7 )ts,,Well No . <br /> Inspect j Total Depth <br /> Screen Length <br /> Filter Pack a3 ' <br /> ff Bentonite Pel is 3 <br /> Permit No . — I d Grout rL I .L0 <br /> Consultant <br /> i Completion-stove pipe ' csristie box <br /> Geologist <br /> Auger O . D . <br /> - Auger I . D . <br /> SAMPLING <br /> Holding Te perature stick'up <br /> Method o c�.. �'- ft 5;7 <br /> L ( _y T <br /> Screening Method Pt T <br /> ABOVEGROUND CHRISTI'-BOX <br /> Tracking Sheet ( y/ n ) COMPLETION COMPLETION <br /> SPOILS Ground Surlary <br /> proal <br /> Storage Method D T / <br /> Contamination Noted - no 1 . . n• <br /> Storage Location 7 .-� tt „• <br /> SPECIAL PERMIT INFO . <br /> 0 <br /> = <br /> Distance to sewer line Hotted 8section -_ <br /> Domestic well on site - yes / i� <br /> If yes , location & distance - — <br /> gravel pock <br /> GROUTING <br /> MATERIALS USED * <br /> fJ <br /> Depth to water 3� I Casing type I G <br /> Mix Ratios Blank ft . Screen4:�- ft . <br /> Installation Method Slot size <br /> quantity Installed Rage cement6 duu <br /> Buckets bentonite <br /> Bags sand/gravel 4" <br /> Filter Pack type/ size <br /> 31 v/3v <br />