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PAGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: r, 1I /S CONSTRUCTION <br /> Premise Address: "o tures+! Well No. $y41 Lt) -Z�j A <br /> Inspector: Total Depth <br /> Screen Length <br /> Filter Pact: <br /> Bentonite Pellets' <br /> Permit No. Grout <br /> Consultant wv�ec. Comoletion-Stove pipe/christie box <br /> Geologist_�V% ftyek t. <br /> Auger O.D. <br /> Auger I.D. <br /> SAI PLING <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> WV&GRCUND CHRIM-BOX <br /> Tracking sheet (y/n) COWL- TAN CCMPLE-FION <br /> --- C7curatl Swlzce <br /> SPOILS <br /> A"CulStorage Method A6 IM�IW4 �h <br /> Contamination Noted - yes/no ({ <br /> Storage Location <br /> — m <br /> SPECIAL PERMIT INFO. <br /> 0 <br /> slotted :. = c <br /> Distance to sewer .re sedon .S <br /> Dcmestic wel n site - yes/no =_ <br /> If yes, 1 at ion & distance <br /> I <br /> — I <br /> ix t;' <br /> GROUTING Gl+�pS +C) ZS•f <br /> MATERIALS USED: <br /> Depth to water Casing type 2- h V�, St4t LCO <br /> Mix Ratios Blan}:-1— ft. ,Screen 16' -t. <br /> Installation Method Slot size V l O <br /> Quant_ty installed Bags cement 3 <br /> Buckets .bentonite <br /> Bags sand/gravel J.b' <br /> Filter Pack type/size <br />