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MONITORING WELL INSTALLATION REPORT <br /> Dates CONSTRUCTION <br /> Premise 'Address:/& S. e-�J�Ce Well No. /l,/J-/y <br /> Inspector: r, 1 Total Depth i <br /> Screen Length <br /> Filter Pack =q <br /> _/ 3� Bentonite Pellets_ <br /> Permit No. Grout <br /> Consultant i ✓� - LI/2 Completion-Stove pipe istiebo <br /> Geologist Sfef� �'1/f�.,>, <br /> Auger O.D. <br /> SAMPLING Auger I.D. 3 �/ <br /> Holding Temperature <br /> Method <br /> .uawP <br /> Screening Method <br /> Tracking Sheet (y/n) <br /> AhOVE-0IIOUND <br /> COMPLETION CMIIM-wx <br /> SPOILS CCMPLE71Of1 <br /> firuxd Sown <br /> piw <br /> Storage Method 5� <br /> contamination Noted - yes/no �n• <br /> Storage Location _n• _ "' <br /> IF <br /> SPECIAL PERMITINFO. Wwwd = V <br /> S <br /> Vnrw Pck <br /> Distance to sewer line <br /> Domestic well on site - yes/no <br /> If yes, location & distance - _._n. - �n <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type <br /> Mix Ratios Blank ft. Screen <br /> Installation Method ft. <br /> Slot size <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br />