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MONITORING WELL INSTALLATION REPORT <br /> Date: O - ��- C CONSTRUCTIONN/ <br /> Premise Address:l2,22 La fky Well No. /'i 4✓ 4` 3 <br /> ) <br /> Inspector: Total Depth 2 5 <br /> l-s f Screen Length Z S- 5- <br /> Filter <br /> Filter Pack <br /> G c� Bentonite Pellets <br /> Permit No. fU� "�/ d 3 Grout <br /> Consultant completion-Stove pip chXi tie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING <br /> Holding Temperature sdck-up <br /> Method ti <br /> mw- <br /> Screening Method 10 <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) COMPLETION COMPLETION <br /> ���Grourd Surface <br /> SPOILS <br /> ` proud <br /> Storage Method 4 0 � -t— <br /> Contamination Noted - yes o ScW �1✓ <br /> Storage Location <br /> = a <br /> — m <br /> = o <br /> — m <br /> SPECIAL PERMIT INFO. _ <br /> o <br /> slotted = c <br /> Distance to sewer line "cpca — <br /> Domestic well on site - yes/no <br /> gravW pack <br /> If yes, location & distance <br /> cl_e� l✓ <br /> GROUTING � <br /> MATERIALS USED: <br /> Depth to water 'V Caaing VC' <br /> ty <br /> Mix Ratios Blank ft. Screen zv ft. <br /> Installation Method Slot size IC' Z <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> \ Filter Pack type/size <br />