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MONITORING WELL INSTALLATION REPORT <br /> Date: 74/a)& O CONSTRUCTION , <br /> Premise Address: Well No. V L! <br /> (,/a)i P/h /��- <br /> Inspector: Total Depth _ 0 <br /> L �'• ��� Screen Length - -� <br /> Filter Pack - <br /> �y Bentonite Pellets <br /> Permit No. 4� IZS� Grout •- 3 --� - <br /> Consultant ,�j77�/S Completion-Stove pipe/christie box <br /> Geologist <br /> Auger O.D. ' • z � , <br /> Auger I.D. Z.S <br /> SAMPLING ,�{{ <br /> Holding Temperature <br /> Method /C(d- <br /> .tl k p <br /> Screening Method <br /> Tracking Sheet (y/n) IWOVE•GNOUND W <br /> CH <br /> RIM GLETuox <br /> OMPLEf1ON <br /> SPOILS or°wC Sots. <br /> /� piwt <br /> Storage Method <br /> Contamination Noted -(y no n• <br /> Storage Location <br /> .l°".d = <br /> SPECIAL PERMIT INFO. <br /> g.rw pent <br /> Distance to sewer line <br /> Domestic well on site - yes/no <br /> If yes, location & distance - —n' I h• <br /> GROUTING MATERIALS USED: <br /> Depth to water Casing type U4- W(f- <br /> Mix <br /> Mix Ratios Blank ft. Screen___/ t. <br /> Installation Method Slot size (�- <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size J <br />