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. T 0 <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: / 2 CONSTRUCTION <br /> i <br /> Premise Address: Well No. /"',' <br /> Inspector: z- '/ Total Depth z <br /> Screen Length <br /> Filter Pack <br /> Bentonite Pellets <br /> Permit No. " Grout 61 <br /> Consultant L/r.` > Completion-Stove pipe/christie box <br /> Geologist 4_,� � C'/�c� S,-��'z <br /> Auger O.D. /�2' <br /> Auger I.D. 5' <br /> SAMPLING -- <br /> Holding Temperature / I !� stIck-up <br /> Method <br /> Screening Method <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) COMPLETION <br /> COMPLETION <br /> Ground Surtwe <br /> SPOILS <br /> Zxo <br /> grout <br /> Storage Method <br /> Contamination Noted - yes/no ft. <br /> Storage Location <br /> SPECIAL PERMIT INFO. <br /> O <br /> slottYd <br /> Distance to sewer line -� "Cton — <br /> Domestic well on site - yesfn& gmvel pack— <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water /� Casing type �� L- <br /> Mix RatiosBlank %`5 ft. Screen ft. <br /> Installation Method Slot size C' P <br /> Quantity Installed - Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel /, <br /> Filter Pack type/size ­41�_3 <br />