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MONITORING WELL INSTALLATION REPORT <br /> Date: 1 1 ✓1 CONSTRUCTION / {,/I <br /> Premise Address: Well No. 1I /J- 2- r?ylAcAa' <br /> Inspector: / 12at1 Total Depth <br /> Screen Length //5 -/OS ' <br /> Filter Pack /Z C2 <br /> (� Bentonite Pellets <br /> Permit No. ��- / Grout PC? <br /> Consultant Lm✓f - f�i(.,irai3' Completion-Stove pipe/christie box <br /> Geologist ��c�Ys/ze�1 <br /> Auger 0.D. /6 ' <br /> Anger I.D. <br /> SAMPLING <br /> Holding Temperatures atick uP <br /> Method <br /> Screening Method <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y COMPLETION COMPLETION <br /> ��Orourd SuAace <br /> SPOILS <br /> proal <br /> Storage Method <br /> Contamination Noted - yes/d „ <br /> Storage Location <br /> e <br /> m <br /> _ o <br /> o <br /> SPECIAL PERMIT INFO. _ - c <br /> 0 <br /> Waned <br /> Distance to sewer line 4 aacdon <br /> Domestic well on site /no _ <br /> If yes, location & distance - <br /> /Occ� <br /> ft. <br /> GROUTING <br /> 22 MATERIALS USED: <br /> Depth to water a J / Casing type ffGc l <br /> Mix Ratios Blank Z�15 ft. Screen /b ft. <br /> Installation Method Slot size <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> �+ / / /�✓/ Bags sand/gravel <br /> ON�fd�Iv✓ �`S� Filter Pack type/size <br /> Cr/1/��lu✓ 3�ot ��i,.C,�r/ <br />