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4 <br /> MONITORING WELL INSTALLATION REPORT <br /> Date• <br /> CONSTRUCTION <br /> Premise Address: � well No. VGU) <br /> Inspector: Total Depth <br /> Screen Length J 2 ,(r, -'lr <br /> R <br /> Filter Pack94 9"­?-�3 <br /> 17� / Bentonite Pellets�3 � <br /> Permit No. 1 ! I Grout `" //3(" <br /> Consultant Completion-Stove pipe/christie box <br /> Geologist V 1 E <br /> Auger O.D. o-z j <br /> Auger T.A. � <br /> SAMPLING <br /> � 1 <br /> Holding Temperature <br /> Method <br /> •qck uP <br /> Screening -Method <br /> Tracking Sheet (y/n) Wsoyecrtouero •� <br /> GOMPLET N CHRISTY-Box <br /> SPOIIrS orow,d S COMPLETIOth <br /> Storage Method it "'n pdwt <br /> n. <br /> Contamination Noted - yea/no <br /> Storage Location n• — <br /> N - <br /> SPECIAL PERMIT INFO. ..cap on — <br /> f 9MV49 Pads <br /> Distance to sewer line U _ <br /> Domestic well on site - ye n — <br /> If yes, location a distance - n• — n. <br /> GROUTING MATERIALS USED: ��,, <br /> Depth to water Casing type SCS- 9-o pk' <br /> Mix Ratios Blank__�-(a ft. Screen_ft. <br /> Installation Method Slot size <br /> Quantity I;n talled Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel_ _ <br /> Filter Pack type/size <br /> ' ti <br />