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f � <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: `y` �� <br /> CONSTRUCTION <br /> Premise Address: ell No. A <br /> Inspe to oral Depth = _ <br /> Screen Length '?5 Al- <br /> Filter Pack a <br /> Bentonite Pellets <br /> Permit No. rout <br /> ConsultantCompletion-Stove pip ' <br /> Geologist <br /> uger O.D. y S y <br /> huger I.D. 3- 7s- <br /> SAMPLING <br /> sSAMPLING _ <br /> Holding Temperature PVE-GROUND <br /> $**-up <br /> Method <br /> Screening Method <br /> Tracking Sheet (y/n) N N. COMPLETION <br /> _ COMPLETION <br /> SPOILS Ground Surface <br /> - grout <br /> Storage Method 1 9 <br /> Contamination Noted - yes�• o �ft• <br /> Storage Location <br /> m <br /> b <br /> SPECIAL PERMIT INFO. Ile <br /> � o <br /> �lottod <br /> Distance to sewer line--!M &*don <br /> Domestic well on site - yesPro) qR <br /> pack <br /> If yes, location & distance N�L-/ <br /> tt. IFit. <br /> GROUTING <br /> TERIALS USED: <br /> Depth to water .�'� asing type -S ✓� �Z �� <br /> Mix Ratios l Ccr« 3 r3..,, lank. s3 i ft. Screen Z5- ft. <br /> Installation Method3lot size G'7O u <br /> Quantity Installed 3ags cement <br /> uckets bentonite <br /> ags sand/gravel <br /> ilter Pack type/size- 03 <br /> ra <br /> ...... //o amicAT a �.r <br />