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MONITORING WELL INSTALLATION REPORT <br /> Dater / c7 C U CONSTRUCTION <br /> Premise Address: t Well No. -/ett- -?— <br /> In, L <br /> Inspector: Total Depth <br /> screen Length 7. <br /> Filter Pack Sr,=24 -AT <br /> Permit No.2Q - <br /> Bentonite pellets n Fs,Consultant Grout � - > f _ <br /> a Completion-Stove pipe christie box <br /> Geologist <br /> Auger O.D.Io ' c1 <br /> SAHPLINO Auger I.D. <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet (y/n) \ <br /> uwve-cnax+D <br /> GOMPI E:x)ry 0"M box <br /> SPOILS <br /> LOMKEIW 4 <br /> Storage Mgthod _tk- <br /> Contamination Noted - ye /no h. <br /> �p = ' <br /> Storage Location n.�n. <br /> _SPECIAL. PERMIT INFO .1w.d <br /> 1KYW1 <br /> o..a pa <br /> Distance to sewer line <br /> Domestic well on site - yes/no <br /> If yes, location 6 distance a <br /> OROUTINO <br /> MATERIALS USED: <br /> Depth to wdterl 5 Casing type LOL)& <br /> Mix Ratios Blank 'I.n ftScree [.r <br /> Inetallati9p Method tie t- . n ft. <br /> Quantity Ipptalled 2�65s Slot size <br /> —4Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> �/ 3 s Filter Pack type/size <br />