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MONITORING WELL INSTALLATION REPORT <br /> Date: ( � ` CONSTRUCTION <br /> Premise Address:-/ Well No. m� <br /> Inspec or: Total Depth <br /> [!22 Screen Length -/n SO <br /> Filter Pack <br /> r1 Bentonite Pellets V 7- ZZ- <br /> Permit <br /> ZPermit No. �U sr� Grout "- <br /> Consultant rle �/W,4e Completio -Stove a hristie box <br /> Geologist aio <br /> Auger O.D. � <br /> Auger I.D. <br /> SAMPLING <br /> Holding Temperature /GG <br /> addo-up <br /> Method <br /> Screening Method =1111M P/!!V <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet ( n) COMPLETION COMPLETION <br /> �.��Ground Surlace <br /> SPOILS <br /> proal <br /> Storage Method rjl,,lv5 <br /> Contamination Noted - yes/no n. <br /> Storage Location &AI si 46 — n. <br /> a <br /> SPECIAL PERMIT INFO. o <br /> doted $ <br /> Distance to sewer line 40 aacdon <br /> Domestic well on site - yea/ <br /> If yes, location & distance - <br /> GROUTING 4 <br /> MATERIALS USED: <br /> { <br /> Depth to water J � Casing type A/C 2 <br /> Mix Ratios Blank 367 ft. Screen Lo-, ft. <br /> Installation Method \ Slot size C]2 <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size ?//L <br />