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MONITORING WELL INSTALLATION REPORT <br /> 1I <br /> Date: ._ .� Z� l CONSTRUCTION <br /> Premise Address: te_ ��� Well No.__ 1t�lJ <br /> Inspector: Total Depth <br /> screen Length �)o <br /> Filter Pack <br /> �� -- <br /> y rw� Bentonite Pellets <br /> Permit No. 6P Grout f =� <br /> Consultant11-103214 �L)AZI(A_ <br /> ' Completion-Stove pipe christie bo <br /> Geologist I <br /> Auger O.D. <br /> i Auger I.D. <br /> SAMPLING <br /> Holding Temperature stldo-up. <br /> Method <br /> Screening Method T <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n COMPLETION COMPLETION <br /> SPOILS Ground Surface <br /> grput <br /> Storage Method <br /> Contamination Noted - no ; � • <br /> Storage Location n• <br /> SPECIAL PERMTT INFO. <br /> — <br /> Distance to sewer line ;� 20/ slotwd sstlian <br /> Domestic well on site -• yespack <br /> r� — <br /> If yes, location & distance <br /> GROUTING <br /> II <br /> MATERIALS USED: <br /> Depth to water �� Casing type <br /> Mix Ratios Blank— ft. Screenft. ' <br /> Installation Method Slot size <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br />- j. <br />