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11� <br /> MONITORING WELL INSTALLATION REPORT <br /> Date:_ <br /> CONSTRUCTION <br /> Premise Address: oV`�/57 Z <br /> Well No. <br /> Inspector: <br /> Total Depth <br /> Screen Length G�- <br /> Filter Pack <br /> Permit No, w -�� Bentonite /Pellets 3 S • <br /> Consultant ,SGrout !,. 5- <br /> Geologist / f Completion-Stove pip christie box <br /> s ��! <br /> Auger O.D. /U <br /> SAMPLING Auger I.D._ <br /> Holding Tempera re_14__= \ <br /> Method <br /> Screening Method <br /> Tracking Sheet (y i <br /> ABOVE-GROUND <br /> COMPLt�ION CMIM box <br /> SP— OILS GO�nPLE71011 <br /> howd Sul�c� <br /> Storage Method <br /> Contamination Noted - e o <br /> Storage Location_ <br /> SPECIAL PERMIT INFO, uoiuG — <br /> ��cuen = S <br /> Distance to sewer line 9."a P"" <br /> Domestic well on site - yes�_�k <br /> If yea,i to ation & dis c <br /> an = <br /> �� <br /> GROUTING <br /> MATERIALS Depth to water .�� ' <br /> Mix Ratios Casing type <br /> Installation Method Blank ft. Screen Zo ft. <br /> Quantity Installed Slot size_ , 07 <br /> Bags cement <br /> Buckets bentonite / <br /> Bags sand/gravel <br /> Filter Pack type/size <br />