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MONITORING WELL INSTALLATION REPORT <br /> Date=//.. p <br /> CONSTRUCTION <br /> Premise Address:/ �i(� P.w,� P &4a ?j <br /> Well No. <br /> Inspectors <br /> Total Depth <br /> Screen Length,�-/ <br /> Filter Packs <br /> Permit Bentonite Pellets <br /> Consultant Grout111-5 8 <br /> Geologist Completion-Stove pe/christie box <br /> Auger O.D. <br /> Auger I.D. <br /> Holding Temperatgre <br /> Method <br /> Screening ,Method-----. 177 T'**49 <br /> Tracking Sheet (y/n) <br /> Nio�.or+ou►� <br /> co~aN BPOZN oo O <br /> Storage Mgthod IMA <br /> Contamination No ed - yes S w. <br /> Storage Locations .�..(i, 40 <br /> BPECIIIL. IT 110• � - <br /> Nciw <br /> Distance to sewer line,_` <br /> Domestic well on site - yes/no <br /> It yes, lopgtion k distance - Zm - M. <br /> OROUTINQ MATERIALS USED$ <br /> Depth to wD.ter� Casing type ✓� r� <br /> Mix RatiosBlank I <br /> Installat4w Method _ ft. Screen ft. <br /> Quantity I09talled Slot size •a�- <br /> Sage cement <br /> Buckets bentonite <br /> Bags sand/gravel-# <br /> Filter Pack type/size 3 <br />