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MONITORING WELL INSTALLATION REPORT <br />Date • <br />Premise Address: <br />Inspector:_ 0. <br />Permit No. 90 <br />Consultanta��� <br />Geologist <br />SAMPLING <br />Holding Temperature 7 b 5�- <br />Method��n <br />Screening Method <br />Tracking Sheet (y/� <br />SPOILS <br />Storage Method <br />Contamination Noted - yes no <br />Storage Location ou, x,f <br />SPECIAL PERMIT INFO. <br />Distance to sewer line <br />Domestic well on site - ye rto <br />If yes, location & distance - <br />GROUTING <br />Depth to water_ <br />Mix Ratios <br />Installation Method {ux <br />Quantity Installed <br />CONSTRUCTION <br />Well No. <br />Total Depth <br />Screen Length is ' <br />Filter Pack /-3 e' <br />Bentonite Pellets 2 <br />Grout S <br />Completion -Stove pipe/ ristie bo� <br />Auger O.D. <br />Auger I.D. G,Z <br />stick-up <br />ABOVE -GROUND CHRISTY-BOX <br />COMPLETION COMPLETION <br />Ground Surface T <br />Zz" ZZ, grout <br />. n. <br />7 n. <br />O <br />C <br />A <br />slotted <br />section <br />� W Pack <br />Ott. v n. <br />MATERIALS USED: <br />Casing type _/ --'VC srN YO ear <br />Blank__ ft. Screen i U ft. <br />Slot size b - <br />Bags cement <br />Buckets bentonite / <br />Bags san' gravel <br />Filter Pack type/size /�O0,4 T./, z-4, <br />