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MONITORING WELL INSTALLATION REPORT <br />Date: 7La, Ax <br />Premise Address: d l/ <br />Inspector: <br />Permit No. O? <br />Consultant <br />Geologist --- <br />SAMPLING <br />Holding Tem erature <br />Method <br />Screening Metho _ <br />Tracking Shee (y/n7) <br />SPOILS <br />Storage Method <br />Contamination Note yes/no <br />Storage Location <br />SPECIAL PERMIT INFO. <br />Distance to sewe 1' e <br />Domestic well on e - yes/no <br />If yes, locatio & 'stance - <br />GROUTING <br />Depth to water <br />Mix Ratios 0 _ <br />Installation Method <br />Quantity Installed <br />CONSTRUCTION <br />Well No. —2-0 <br />Total Depth <br />Screen Length <br />Filter Pack <br />Bentonite Pellets 3 <br />Grout <br />Completion -Stove pipe Christie box <br />Auger O.D. fog <br />Auger I.D. <br />�t <br />Ground Surface <br />proof <br />ft. <br />.�®h. <br />MATERIALS USED: <br />Casing type S'c-. q0 <br />Blank ft. Screen a-0 ft. <br />Slot size <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />