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MONITORING WELL INSTALLATION REPORT <br /> Date:_ CONSTRUCTION <br /> Premise Address:_�g/df (,�_ ��r, Well No. •YyIC-� �7 <br /> Inspector 4 - ria • Total Depth <br /> Screen Length PM <br /> Filter Pack a <br /> � // /O Bentonite Pelletsj, 5/ >n <br /> Permit No <br /> CZ. 6 Grout_ <br /> Consultant Completion-Stove pipe/ ris a box <br /> Geologist <br /> Auger O.D. �C <br /> Auger I.D. <br /> SAMPLING _ <br /> ° <br /> Holding Temperature stldaup <br /> Method �...Q <br /> _ �.Q - c a, <br /> Screening Method <br /> ABOVEGROUND CHRISTY-BOX <br /> Tracking Sheet y n) COMPLETION COMPLETION <br /> SPOILS <br /> / / � Qrout <br /> Storage Method ce.K <br /> Contamination Noted -(Y-elo/no n• <br /> Storage Location n. <br /> ft. <br /> — "IB <br /> SPECIAL PERMIT INFO. — <br /> Woned = <br /> Distance to sewer line s�clion —_ <br /> Domestic well on site - yes/no — �vW p <br /> If yes, location & distance - <br /> ack <br /> GROUTING <br /> MATERIALS USED: / <br /> Depth to water Casing type pl/C- $Cy <br /> Mix Ratios Blank eo ft. Screen— ft. <br /> Installation Method Slot size D. n j <br /> Quantity Installed Bags cement_ f <br /> Buckets ntonite I <br /> Bagsgravel <br /> Filter Pack type/size s� <br />