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4 <br /> MONITORING WELL INSTALLATION REPORT <br /> k' <br /> • E <br /> I <br /> Date:. r / �v I" CONSTRUCTION <br /> Premise Address: Well Well No.__�_�✓ r i <br /> Inspector: Total Depth %s F <br /> A i Screen Length__./5 ` <br /> t� Filter Pack 15- - <br /> Permit No. Y .. <br /> Bentonite Pellets - 3 <br /> Grout - v! <br /> Consultant �/�It� Completion-Stove pipdVciWiltie box <br /> Geologist jcs"•r(_ _O rfl�xp <br /> Auger Q.D. 42 <br /> kAuger I.D. <br /> SAMPLING <br /> cstk*-up <br /> Holding Temperature i G:tf <br /> Method /"7, <br /> Screening Method 7WW <br /> 1i AE;;�4ROUND <br /> Tracking Sheet (y n COMPLETION CHMSTY-BOX <br /> COMPLETION <br /> i Ground Surlwe <br /> SPOILS <br /> grout <br /> Storage Method WI-V4 <br /> Contamination Noted <br /> Storage Location i �• <br /> G ? � ft• <br /> � w <br /> SPECIAL, PERMIT INFO. <br /> e <br /> Distance to sewer line mon I <br /> Domestic well on site <br /> Ifyes, location & distance <br /> •� _eft, ft. <br /> GROUTINO <br /> # MATERIALS USED: <br /> Depth to water Casing ty <br /> Mix Ratios t Blank ft. Screen /6ft. <br /> Installation Method ;I Slot size <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> ✓ Bags sand/gravel <br /> E Filter Pack type/eize <br />