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MONITORING WELL INSTALLATION REPORT <br />Date: <br />Premise Address: /x23 �� �,ar <br />Inspector• <br />Permit No. Z <-.5- <br />Consultant <br />.sConsultant <br />Geologist` <br />SAMPLING <br />Holding Temperature WO <br />Method �,, to <br />Screening Method <br />Tracking Sheet (yftj) <br />SPOILS <br />Storage Method -Bloc <br />Contamination Noted - yes no <br />Storage Location o-., _n <br />SPECIAL PERMIT INFO. <br />Distance to sewer line Baa <br />Domestic well on site - yes/® <br />If yes, location & distance - <br />GROUTING <br />Depth to water__ 9 . <br />S <br />Mix Ratios <br />Installation Method ue <br />Quantity Installed <br />CONSTRUCTION <br />Well No. j0;91 c,-) ' 3 <br />Total Depth <br />Screen Length <br />Filter Pack_T <br />Bentonite Pellets ,Z <br />Grout ' 3 <br />Completion -Stove pipe/ a box <br />Auger O.D._ <br />Auger I.D. e 2 - <br />stick -up <br />7,1 T <br />ABOVE -GROUND CHRISTY-BOX <br />COMPLETION COMPLETION <br />Ground Surface <br />Zxo <br />proal <br />-7-n s n. <br />— 'es <br />_ c <br />— a <br />abtwd <br />aft-roon — <br />I4: = g pad* <br />MATERIALS USED: <br />Casing type QVC -SIC/," vc f " <br />Blank 9 ft. Screen -O ft. <br />Slot size 0. 0" <br />Bags cement <br />Buckets bentonite <br />Bags an /gravel <br />Filter Pack type/ size ?•,Z lc-_ <br />