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4. <br /> r MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: L well No. <br /> Inspector: - L ,J _ Total Depth 1 t/O <br /> Screen Length <br /> Filter Pack_ <br /> Bentonite Pellets )E7,-i-Z3_ ,s - z b <br /> Permit No. Grout - Z C7 S <br /> Consultant cG7" Completion--Stove pipe/ciristie be <br /> Geologist A41 //An/.Sd` <br /> Auger O.D. 6 <br /> Auger I.B. 3 <br /> SAMPLING <br /> Holding Temperature 4`C- <br /> Method �� G <br /> •uaa-up <br /> Screening Method f1- NU <br /> Tracking Sheet (Y n? ABOVEGROUND CrIA&Y-box <br /> COMPLETION COMPLETION <br /> SPOILS amundSlj T <br /> proal <br /> Storage Method 0,1 S•Af <br /> Contamination Noted - yes o q• <br /> Storage Location__ <br /> 4 <br /> O <br /> monad — <br /> SPECIAL PERMIT INFO. - <br /> - prrral pack <br /> Distance to sewer line 's — <br /> Domestic well on site - ye <br /> If yes, location & distance�- <br /> GROUTING MATERIALS USED: �� <br /> Depth to water _ - 3z Casing type ;> �C- SC/y- Yo <br /> Mix Ratios Blank ft. Screen EI/,j— ft. <br /> Installation Method r-Pill Slot size <br /> Quantity Installed _ ,.fyd Bags cement <br /> Buckets bentonite. _ l <br /> Bags sand/gravel <br /> Filter Pack type/size-_+'V--2 Ami/. <br />