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MONITORING WELL INSTALLATION REPORT <br /> Date: L/ _ & CONSTRUCTION <br /> / <br /> Premise Address: Well No. !1 y <br /> Inspector: Z Total Depth / 2Z. S <br /> - a f '� Screen Length /Z _ �- %/O <br /> Filter Pack <br /> Bentonite Pellets <br /> Permit No. Grout -------- <br /> Consultant G✓is ss Completion-Stove pip4ichriatle box <br /> Geologist- ( ,'„� a <�rs <br /> - --- <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING <br /> HoldingT� perature stidt-uP <br /> Method <br /> Screening Me hod i T <br /> ABOVEGROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) COMPLETION COMPLETION <br /> SPOILS taco 7 — <br /> 9100A — <br /> a«a <br /> Storage Method, <br /> Contamination Ned - yes/no n• <br /> Storage Location n• <br /> n. <br /> SPECIAL PERMIT INFO. <br /> — e <br /> Distance to sewer liney� <br /> Domestic well on Bite - yee/& _ 9MVWPaa <br /> If yes, location & distance - <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 />