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MONITORING WELL INSTALLATION REPORT <br /> Datei_ l ill L' <br /> CONSTRUCTION <br /> Premise Address: �✓ l � � / ��._� <br /> Well No, f Gtr <br /> Inspector:_ —I /——, <br /> Total Depth <br /> Screen Length_/l <br /> Filter Pack <br /> Permit No. 15FO-KYq Bentonite pellets Ice 1 <br /> Consultant - r ?I I., Grout <br /> Geologist % Completion-Stove pipe/Christie box <br /> Auger O.D. 10 <br /> SAMPLING <br /> Auger I.D. I1 ' <br /> Holding Temperature L� 0 <br /> Method <br /> Screening Method P-c , •mtiP <br /> Tracking Sheet (y/n) <br /> AUOVE-GHOIWD <br /> CO:.w:E7iDH DOMWX <br /> SPOILS COmKE-Fjo" <br /> bona&A•e• <br /> Storage M thud <br /> � <br /> Contamination Noted - yes/no j <br /> Storage Lpcation — f�'_ry, _ n• <br /> SPECIAL PERMIT INFO u01Ma <br /> •«von <br /> Distance to sewer line �• �' o v�•�w�a <br /> Domestic well on Bite - yesfno-j <br /> If yes, loq.ation & distance - ��-ry• <br /> n. <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to w#,ter <br /> Mix Ratios /' Casing type IPLiC <br /> Blank /,0 <br /> Inetallatlpn Method (i��% i ft, screen is ft. <br /> —1� Slot size •G z. <br /> Quantity IDgtalled - \o_ ii Bags cement Z c-e <br /> Buckets bentonite f C <br /> Bags sand/gravel <- W -d- I <br /> Filter Pack type/size_ Z rte <br />