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MONITORING WELL INSTALLATION REPORT <br /> Date: III�a��o CONSTRUCTION/ / <br /> Premise Address: 0 ' LAM QMN"!. Well No. 5('3_ t <br /> Ins_oector• Total Depth <br /> Screen Length <br /> Filter Pack <br /> Bentonite Pellets <br /> Permit No. Grout <br /> Consultan`s Completion-Stove pipe/christie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING <br /> _ �sbck�p <br /> Folding Temperature <br /> Method <br /> Screening Method ._ <br /> ABOVE-GROUND CNAIS?Y-20X <br /> Tracking Sheet (y/n) Cv MFL Ei!ON COMPLETION <br /> Ground SuAxe <br /> SPOILS grout <br /> Storage Method <br /> Contamination Noted - yes/no 5 ft <br /> Storage Location <br /> _ f Law <br /> X1(1 <br /> m <br /> 0 <br /> SPECIAL PERMIT INFO. <br /> cloned <br /> Distance to sewer line— <br /> on —_ <br /> Domestic well on site - ves/no <br /> gmyW pack <br /> I: yes, location & distance - <br /> ft. <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type N�.0� <br /> Mix Ratios Blank �t. Screen `t• <br /> Installation Method Slot size <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> . -_ter Pack type/size <br /> otal Billed Time Per Site <br /> ate Permit Finalized <br />