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MONITORING WELL INSTALLATION REPORT <br /> Date: 7- :5) CONSTRUCTION <br /> Premise Address: 3"� �✓ 7 <br /> Well No. <br /> Inspector• Total Depth <br /> Screen Length_ <br /> Filter Pack <br /> Bentonite P leets <br /> Permit No. �3 O Grout- <br /> -21 <br /> rout (� <br /> Consultant_ <br /> O h yV1p h✓cit Completion-stove pip Christie box <br /> Geologist_ <br /> Auger O.D. <br /> Auger I.D._ <br /> SAMPLING <br /> Holding Temperature i LC atcki+P <br /> Method S 5 oy,^ <br /> I 6E <br /> Screening Method V <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y COMPLETION <br /> COMPLETION <br /> SPOILS Gmund Surlace <br /> Storage Method c�h D5��C. ZoFow <br /> Contamination Noted - yes/(9> <br /> Storage Lo.,cation ,`n <br /> SPECIAL PERMIT INFO. — • <br /> e <br /> Distance to sewerline v Waited <br /> section <br /> Domestic well on site - yes/ o <br /> If yes, location 6 distance - : = grave1Pack <br /> GROUTING <br /> c / MATERIALS USED: <br /> Depth to wat r Casing pe <br /> Mix Ratios :;y Blank ft. m en o ft. <br /> Installation Me hod Slot size <br /> Quantity Installed / Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size Z 'Z- <br />