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M <br /> MONITORING WELL INSTALLATION REPORT <br /> Dates aI01 1 I ,, .. 11 ��LL jj CONSTRUCTION <br /> Premise Address : 6 Wa� .J� OC(cell No . <br /> Inspector • / Total Depth —1; <br /> Screen Length <br /> Filter Pack <br /> p Bentonite Pellgts <br /> Permit No . 1 � � 3 � `� � Grout C.o� � <br /> consultant ypD . Completion-Stove pipe Irietie ox <br /> Geologist )o 0 <br /> Auger O . D . <br /> Auger I . D . <br /> SAMPLING <br /> Holding emperature <br /> elckoup <br /> Method9 ,ea <br /> Screening Method f S D V <br /> ABOVEmGROUND CHRISiY•BOX <br /> Tracking Sheet ( y/n ) COMPLETION COMPLETION <br /> SPOILS Ground S + <br /> }— proal <br /> Storage Method _ Ci--MA.v+� <br /> contamination Noted yes / no 1-27 <br /> . ft• <br /> Storage Location 3Q ft. <br /> 33 ft. <br /> IF <br /> R <br /> IF <br /> SPECIAL PERMIT INFO . <br /> _ _ o <br /> Distance to sewer line <br /> on = $ <br /> Domestic well on site - yep no <br /> If yes , location & distance - — <br /> GROUTING <br /> MATERIALS USED : <br /> Depth to water .3 F / casing type I sl <br /> Mix Ratios Blanka3 ft . Screen ft . <br /> Installation Method Slot size . D2' <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/ size <br /> 311,30 <br />