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MONITORING WELL INSTALLATION REPORT <br /> Date:/, CONSTRUCTION y <br /> Premise Addreep: 4141qq I pm <br /> Well No. <br /> .7 v <br /> Inspector• Total Depth. <br /> Screen Length e-i <br /> Filter Pack-, . <br /> Bentonite Pellets Z � <br /> Permit No. Grout <br /> Consultantcompletion-Stovei e <br /> p p /ghristie b <br /> Geologist_ O� <br /> Auger O.D. <br /> Auger I.D. =�1• �f' <br /> SAMPLING <br /> Holding Temperature L, /� atkk'up <br /> Method. nt/a <br /> IffT <br /> Screening Method<</ <br /> ABOVE-GROLIND CHRISTY-BOX <br /> Tracking Sheet (y/n) - COMPLETION COMPLETION <br /> SPOILS � _f <br /> grout <br /> Storage Method • -� '�- moo(-�F/� <br /> Contamination Noted - ye, ft. <br /> ft. <br /> Storage Locatiory a - '<a< � <br /> LX.S n <br /> SPECIAL PERMIT INFO. = x <br /> _ c <br /> 0 <br /> Distance to sewer line wo;w $ <br /> mon <br /> Domestic well on site - yes/B8 <br /> If yes, location & distance- qm�*pack <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water, Casing ty e����% <br /> Mix Ratios_ ,.,K"i"'* (' Blank ft. Screen /.r ft. <br /> Installation Method Slot size .OZ- <br /> Quantity Installed '%��r� Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel t`�• `Sita -+ <br /> Filter Pack type/size d <br />