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PAGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date:�o IZIAe CONSTRUCTION <br /> Premise Address: Well No. <br /> Inspector:Y -�-� Total DeathIsm <br /> Screen Length <br /> --S <br /> Filter Pack, <br /> Bentonite Pellets d • <br /> Permit No. Grout <br /> Consultan` Comoletion-Stove pipe/christie box <br /> Geologists . <br /> Auger OO.D. <br /> Auger I.D. <br /> SAMPLING <br /> ` stickup <br /> Folding Temperature <br /> Method <br /> Screening Method <br /> ABOVE-GROUND CNRISV-BOX <br /> Tracking Sheet (y/n) td.P LF7!ON GCMIPL'-TION <br /> Grcurrd Swlwe <br /> SPOILS grad <br /> Storage Method AL1 w4utoo/ <br /> Contamination Noted - yes/no (t. <br /> Storace Locationg, .— - <br /> a <br /> — m <br /> m <br /> SPECIAL PERMIT INFO. = c. <br /> 0 <br /> slotted <br /> Distance to sew line sacdon s <br /> Domestic wel on site - yes/no ;:f;_ = gavel pack <br /> It ves, 1 anon & distance <br /> ev— <br /> GROUTING <br /> MATERIALS USED: <br /> Deo-1h to water Cas-; ng type - <br /> M'_:< Ratios 10 �7e�t Blank %J4 ft. .Screen IO <br /> Ins'-.allat on Method slot size • Ol0 <br /> wantl�y installed Q_. tem_ Sacs cement <br /> a Buckets bentonite <br /> Sacs sand/gravel <br /> Filter Pack type/size a/t-L <br />