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MONITORING WELL INSTALLATION REPORT <br /> Date i � � L � <br /> CONSTRUCTION <br /> Premise Address:91� Well No. /uLv- v r�-fitJ <br /> aro G2 t� <br /> Inspectors f <br /> Total Depth f{3 <br /> Screen Length 7_�- _ <br /> Filter Pack�i. �- <br /> Permit No. <br /> Bentonite Pellets—tti4'�• <br /> - Grout <br /> Consultant <br /> Completion-Stove pipe Christie box <br /> Geologist <br /> Auger O.D._(� <br /> Auger I.D. <br /> SAMPLING <br /> Holding Temperature <br /> Method <br /> •tldcvp <br /> Screening Method i <br /> Tracking Sheet (y/n) woVE-GROUND <br /> GOWLET10N CHHIM-box <br /> SPOILSc0mKIET"I <br /> .�...�_ekowia Sure• <br /> Storage Mqthod �„ ��c <br /> Gz °'°`" <br /> Contamination Noted - yes,/no G h <br /> Storage Location doh. _ p' <br /> SPECIAL PERMIT Iffo N°'wd 1 <br /> •.pion <br /> _ pnv`Ipaclt <br /> Distance to sewer line = <br /> Domestic well on site - yes/no r = <br /> If yes, location & distance - n• _ n. <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water S� Casing type oc/ <br /> Mix Ratios Blank ars ft. Screen-1--f ft. <br /> Installatisw Method L � Slot size <br /> Quantity IGptalled ���_ Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> � ( Filter Pack type/size <br />