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MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> (112 - <br /> - /�D CONSTRUCTION <br /> Premise Addr'e+s : 2 7 J��LGy Well No. <br /> Inspector.,- ( A.� / Total Depth -' <br /> Screen Length 15-1 <br /> Filter Pack '3 <br /> Bentonite P llets <br /> Permit No. Grout <br /> Consultant Completion-Stove ipe/ hrietie _box <br /> Geologist <br /> Auger 0.D. /0 <br /> Auger I.D. <br /> SAMPLING - _------- - — <br /> Holding T mperatur 7 G� atk*-'P <br /> Method <br /> Screening MethodABOVE <br /> �4 T <br /> Tracking Sheet (yf n) CO'LETIOND CHRISTY43OX <br /> COAAPi.ETION <br /> SPOILS <br /> gi"ut <br /> Storage Method ,y <br /> Contamination Noted '(ye s no �• <br /> Storage Location n• <br /> go <br /> .s <br /> A <br /> SPECIAL PERMIT INFO. = . <br /> Distance to sewer line s�ictlon ; <br /> Domestic well on site - ye nod �vil t <br /> If yes, location & distance r :i .^ <br /> tt. LIU <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type Poo CC' <br /> Mix Ratio Blank_4 • ft. Screen �ft. <br /> Installation Metho rcc Slot size '0 <br /> Quantity Installed Bags cement_ .- <br /> U Buckets bentonite l <br /> Bags sand/gravel t <br /> Filter Pack type/size T: 3 <br /> k- <br />