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MONITORING WELL INSTALLATION REPORT <br /> Date: CC!� �gNg .. ,y/,eS'?Y1VGT7ti i/ <br /> Premise Address: 6a5 Ld Well No. /',�✓ oc /�(,/ y <br /> Inspector• <br /> _ Total Depth a S ' <br /> " 71A Screen Length_ <br /> Filter Pack <br /> _ Q Bentonite Pellets <br /> Permit No. O ! Grout <br /> Consultant ,<cG/ Tc ,,r/cs Com le 'o Stovep pip /chi+=* -x <br /> Geologist a c /=nom p ./.�j-oyPU <br /> Auger O.D. ' <br /> SAMPLIAuger I.D. <br /> NG <br /> Holding Temperature Mick-up <br /> Method <br /> Screening Method <br /> ABOVE-GRWND <br /> Tracking Sheet (y/n) COMpLETION CHRISTY-BO% <br /> COMPLETION <br /> SPOILS <br /> Ground Su lan <br /> groin <br /> Storage Method <br /> Contamination Noted - yes/no n. <br /> Storage Location — ft. <br /> n. <br /> — e <br /> SPECIAL PERMIT INFO. = z <br /> o <br /> = 'EDistance to sewer line Monod oocoos -_ <br /> Domestic well on site - yes/no <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type >"V L- <br /> Mix Ratios Blank ft. Screen ft. <br /> Installation Method Slot size O 2 <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br />