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MONITORING WELL INSTALLATION REPORT <br /> Date:_ &/ ,f 0 CONSTRUCTION <br /> Premise Address: Z70c1 [,,I'M"' Uyj Well No. W �Z <br /> Inspector: Total Depth <br /> Screen Length <br /> Filter Pack <br /> Bentonite Pellets 0 C� <br /> Permit No. Grout a(� <br /> ConsultantCompletion-Stove pipe/ ristie box <br /> Geologist s" <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING <br /> Holding Temperature atkk•up <br /> Method <br /> Screening Method <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) COWPLETION COMPLETION <br /> SPOILS Surface + <br /> Z/1 Z/7 grout <br /> Storage Method_ l;(� <br /> Contamination Noted - yes/no �• <br /> Storage Location h• <br /> D/j saw n. _ <br /> M <br /> SPECIAL PERMIT INFO. _ <br /> _ A <br /> slotted <br /> Distance to sewer line_ wocton = <br /> Domestic well on site - yes/no _ 9 al pack <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type %.`aC Q') N(- <br /> Mix RatioB M Blank ft. Screen ft. <br /> Installation Method 'IpJMILC Slot size <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br />