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MONITORING WELL INSTALLATION REPORT <br /> Date: �- � G D <br /> CONSTRUCTION <br /> Premise Address: //leWell No. <br /> Inspector• Total Depth 3 D <br /> Screen Length___ <br /> Filter Pack 3 <br /> c Bentonite Pellets 1-3- 1,1 <br /> Permit No. / Grout - O <br /> Consultant �/6�z-i✓J� Completion-Stove pi chrietie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING <br /> Holding Temperature stk*-up <br /> Method <br /> Screening Method <br /> ABOVE-GROUND CHRISTY•BOX <br /> Tracking Sheet (y/n) COMPLETION <br /> COMPLETION <br /> SPOILS Ground Sudace <br /> Z/7 <br /> proof <br /> Storage Method <br /> Contamination Noted - yes/no <br /> Storage Location n, <br /> n. <br /> SPECIAL PERMIT INFO. <br /> A <br /> Distance to sewer line sloped — <br /> "coon — <br /> Domestic well on site - yes/no _ <br /> If yes, location & distance - g *I pack <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type <br /> Mix Ratios Blank ft. Screen ft. <br /> Installation Method Slot size <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br />