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MONITORING WELL INSTALLATION REPORT <br /> Date: OZ 7 d CONSTRUCTION ,V <br /> Premise Addre s: Well No. <br /> 3 <br /> 6� � ��u <br /> Inspector: Total Depth <br /> c5 Screen Lengths <br /> Filter Pac <br /> �/}} ! c� Bentonite Pellets <br /> 7 - 3 - <br /> Permit No. o - �ZJ I Grout _W/ > a <br /> ConsultantCompletion-Stove pipe/christie box <br /> Geologist a LRS //fib <br /> Auger O.D. •2 5 <br /> Auger I.D. <br /> SAMPLING <br /> Holding Temperature <br /> Method Ica <br /> �tickup <br /> Screening Method <br /> Tracking Sheet (y/n) ABOVE-0HOUND ` <br /> CO <br /> COMPLETION MPLE N <br /> COOMPLETION <br /> SPOILS Gla"S <br /> Storage Method C� <br /> Contamination Noted -(ye no '�j H• <br /> Storage Location <br /> 0 <br /> SPECIAL PERMIT INFO. <br /> _ 9.aw pack <br /> Distance to sewer line <br /> Domestic well on site - yes/ Ta- <br /> If yes, location & distance - —n' I n' <br /> GROUTING MATERIALS USED: /j 9 <br /> Depth to water Casing t pe Ale 0617 <br /> Mix Ratios_ Blank ft. Screen 2V0 ft. <br /> Installation Method slot size 0. ow <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size - ,� <br />