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MONITORING WELL INSTALLATION REPORT <br /> Date: � Z_ p CONSTRUCTION 0 1 <br /> Premise Addr f �=� /C.f-' Well No. <br /> Inspector: nuI Total Depth <br /> Screen Length_ /17 <br /> Filter Pack_i___11{ A+J <br /> Bentonite Pellets S <br /> Permit No. �° lr ' 27�Y Grout rn,"N'1 11 C&.r..(_- <br /> Consultant Completion-Stove pipe/christie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. X .611 <br /> SAMPLING ! q - - - --- <br /> Holding Temperature stk -up <br /> Method <br /> Screening Method <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) COMPLETION COMPLETION <br /> SPOILS � � + <br /> Storage Method <br /> Contamination Noted - yes/no O <br /> Storage Location�i _�P[y C 13? n. <br /> — 7 <br /> _ o <br /> — r <br /> SPECIAL PERMIT INFO. = � <br /> — o <br /> Wonod _ c <br /> Distance to sewer line A)IA "cdon $ <br /> Domestic well on site - yes/no <br /> If yes, location & distance <br /> GROUTING <br /> MATERIALS USE :S00 <br /> Depth to water ' Casing type? S 'S ' S1 <br /> Mix Ratios 2 1 .,.--� �il!a Blank S7 ft. Screen ft. <br /> Installation Method Slot size '05D <br /> Quantity Installed 7 Bags cement" 4� % <br /> Buckets bentonite Z S <br /> Bags sand/gravel is71 <br /> Filter Pack type/size >�G <br />