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MONITORING WELL INSTALLATION REPORT <br /> Date: l /Z S �T( CONSTRUCTION <br /> Premise Address: Well No. <br /> Inspector: Total Depth <br /> L�1 Screen Length <br /> Filter Pack <br /> Bentonite Pellets lv•` -� <br /> Permit No. Grout I%.;fl Z <br /> ConsultantCompletion-Stove pipe/christie box <br /> Geologist Cd-,s _ <br /> Auger O.D. <br /> SAMPLING Auger I.D. o L� <br /> Holding Temperature 4-0 <br /> Method Aag /C c^ <br /> .tkx�,p <br /> Screening Method_ ny/-( <br /> /r W/Tracking Sheet ,tom) AUOVE-GROUND <br /> co�.wtt�ioN crw�snr.box <br /> ca,nPLET�oN <br /> SPOILS pryer S�rtrc0 <br /> Storage Method ,Qb piwl <br /> Contamination Noted - yes no <br /> Storage Location n• — <br /> CSII.' <br /> - 4 <br /> NonrO _ <br /> SPECIAL PERMIT INFO. <br /> p a.W P-k <br /> Distance to sewer line >460 <br /> Domestic well on site - yes/�f� <br /> If yes, location & distance n. _ _ n• <br /> GROUTING MATERIALS USED: <br /> r <br /> Depth to waterCasing tip :56-/,If .40 <br /> Mix Ratios Blank ft. Screen 2-4:L_ft. <br /> Installation Method Slot size �. (] <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br />