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MONITORING WELL INSTALLATION REPORT <br /> Date: �lJ' 761 CONSTRUCTION <br /> Premise Address: 04/ �M✓�lWell No. X4 (� 7 <br /> Inspector• _ s /.'F - Total Depth �U <br /> Screen Length �/d - ZU <br /> Filter Pack 7c" <br /> ti s Bentonite Pellets /gr <br /> -l6 z <br /> Permit No. Grout —17 - 0 <br /> Consultant T - <br /> Consultant Completion-Stove pipe chr'sti <br /> Geologist /CPUs% /7/r•?tj / <br /> Auger O.D. CJ" <br /> Auger I.D. <br /> SAMPLING <br /> Holding• Temperat* stldt-up <br /> Method 4j <br /> . V' " i CL <br /> Screening Method �- <br /> /1BOVE-GROUND CHRiSTY-BOX <br /> Tracking Sheet ,(`y� COMPLETIONCOMPLETIONCOMPLETION <br /> Vjn) C3rourd Surface <br /> SPOILS <br /> proal <br /> Storage Method_ i(9 S SIG <br /> Contamination Noted - ye no �ft. <br /> Storage Location n• <br /> w <br /> SPECIAL PERMIT INFO. _ <br /> _ o <br /> eloi <br /> Distance to sewer line 7 SCS sso0on — $ <br /> Domestic well on site - yes <br /> If yes, location & distance - <br /> �AC) <br /> GROUTING <br /> MATERIALS USED: 1/ <br /> 2 � <br /> Depth to water • � Casing type <br /> Mix Ratios Blank- ft. Screen 7_0 ft. <br /> Installation Method Slot size .!7 Z <br /> Quantity Installed Bags cement ? S4< f <br /> Buckets bentonite <br /> Bags sand/gravel <br /> � /�� _�y� j Filter Pack type/size/vres✓�►� <br /> ,s <br />