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i <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> CONSTRUCTION ' <br /> Premise 'Address: f 3a ��✓� '� Well No: <br /> Inspector: Total Depth <br /> r\ °' Screen Length_ <br /> Filter Pack <br /> �, Bentonite Pellets <br /> Permit No. Grout % <br /> Consultant e Cam lGeologistetion-Stove^ iP / <br /> christie box <br /> Auger <br /> O.-D. <br /> Auger <br /> SAMPLING „ <br /> HoldingTemp a urs -C. <br /> Method_ <br /> �tick up <br /> Screening Method_„1am--,,� _ <br /> i <br /> Tracking Sheet ( n <br /> ABOVE-GROUND <br /> coowftt Flom Cti im-BOx <br /> SPOILS COeeKO10ti <br /> Gmurd S <br /> Storage Method �is-A,/C <br /> Contamination Noted - yes/ ! h• <br /> Storage Location �h' <br /> — d <br /> SPECIAL PERMIT INFO. Waited — <br /> 6 6ectwa — <br /> Distance to sewer line = <br /> r — <br /> Domestic well on site - yes/� <br /> If yes, location & distance - n, n <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water <br /> Casing t <br /> Mix Ratios Blank -ft. Screen— <br /> Slot <br /> Z t7 ft.' <br /> Installatipn Method Screen <br /> Slot si � P' <br /> Quantity Installed Bags cement 7 <br /> Buckets bentonite _ <br /> Bags sand/gravel L- <br /> Filter Pack type/size <br />