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t <br /> N w <br /> MONITORING WELL INSTALLATION REPORT <br /> Date• /�`//� CONSTRUCTION <br /> Premise Address: 3 ���Y(ls Well No. <br /> Inspector• Total Depth__ O <br /> Screen Length-?O <br /> Filter Pack�lv�-.;,( <br /> 7 Bentonite Pellets 0 . <br /> Permit No. �("�U�O Grout_S'(-� C-gu-- <br /> Consultant Gu Completiow-8ov p e/christie box <br /> Geologist_ <br /> Auger 0.D. <br /> Auger I.D._G" <br /> SAMPLING <br /> Holding Temperature �(-C� atk*i+P <br /> MethodR A 11V-3 <br /> Screening Method <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet n) COMPLETION <br /> COMPLETION <br /> SPOILS Ground Sumacs <br /> > Mout <br /> Storage Method �j <br /> Contamination Noted - yes no Tib ft, <br /> Storage Location__D�- <br /> ��• .tt. <br /> = m <br /> SPECIAL PERMIT INFO. <br /> — c <br /> — o <br /> Distance to sewer line slonsd ; c <br /> Domestic well on site <br /> asction <br /> - •• <br /> If yes, location & distance - " = prnvWpack <br /> GROUTING <br /> MATERIALS USED- <br /> Depth to water O <br /> CasiniL�— <br /> Quantity <br /> Mix Ratios < BlankZ'-V ft. <br /> Installation Method ��i�� e Slot size O Installed Bags cement <br /> Buckets bentonite ! <br /> Bags sand/gravel / 6 <br /> Filter Pack type/size__ •.L <br />