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MONITORING WELL INSTALLATION REPORT <br /> Dates <br /> CONSTRUCTION <br /> Premise 'Address: /✓C-bCI /+- G.,l/ICDI/-I Well No. <br /> Inspector: Total Depth_ 3S <br /> Screen Length 5 Zo <br /> Filter Pack <br /> Permit No. ��—�� Q Bentonite Pellets_ <br /> Grout <br /> Geologist <br /> Consultant .�� Completion-Stove pipe christie b <br /> Auger O.D. <br /> Auger MPI.D. 3 <br /> SALING <br /> Holding Temperature <br /> Method <br /> .nawp <br /> Screening Method <br /> Tracking Sheet (y/n) <br /> ABOVE-OIIOUND <br /> OUMPU ION CNHISTY bU1( <br /> S OI S cOrtPLET1oN <br /> 0"W4 S�rlac� <br /> Storage Method / o""" <br /> Contamination Noted - yes/no 4 <br /> Storage Location <br /> n <br /> SPECIAL PERMIT INFO. <br /> /U = VbVA Pack <br /> Distance to sewer line (® _ <br /> Domestic well on site - yes o _- <br /> If yes, location & distance <br /> GROUTING <br /> �j MATERIALS USED• <br /> Depth to water ✓ / Casing type �/� <br /> v <br /> Mix Ration Blank <br /> Installatipn Method ft. Screen ft. <br /> Slot size <br /> Quantity Ingtalled Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br />