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MONITORING WELL INSTALLATION REPORT <br />Date: <br />Premise Address:__ <br />Inspector• <br />i[Jaf_i e <br />Permit No. 2 <br />Consultant .L&6, <br />,✓ L® 4 <br />Geologist 4&j sj <br />SAMPLING <br />Holding Temperature <br />Method <br />Screening Method_ <br />Tracking Sheet (y/'n) <br />SPOILS <br />Storage Method <br />Contamination Noted - yesno <br />Storage Location <br />SPECIAL PERMIT INFO. <br />Distance to sewer 1'ne <br />Domestic well o ite - yes/no <br />If yes, locatio distance - <br />GROUTING <br />Depth to water <br />Mix Ratios <br />Installation Method 7-770 <br />Quantity Installed <br />Well No. —/ <br />Total Depth <br />Screen Length -p <br />Filter Pack <br />Bentonite Pellets <br />Grout_ CID At <br />Completion -Stove pipe christie box <br />Auger O.D. <br />Auger I.D. " <br />c <br />®rout <br />. ft. <br />}t. <br />®ft. <br />slotted <br />section <br />MATERIALS USED: <br />Casing type eS' <br />Blank ft. Screen ft. <br />Slot size <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />