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T <br /> " PAGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: 2 U CONSTRUCTION <br /> Premise Address:3 00 ' ""t't r'n'. Well No. TV6s fAyj- 4 <br /> _ Inspector: Total Depth 15' <br /> �G G&A Screen Length 20' 4 s C ' <br /> Filter Pack *ZZiz "A"c_< ._ S6� '?Ts <br /> Bentonite Pellets ` 2_�-- <br /> Permit No. 0` r`�Y Grout _ � SS' <br /> Consultant LJr, -e_r` aJurk Completion-Stove pipe/christie box <br /> Geologist *MVE-P[PE (ASO AeAbO <br /> Auger O.D. G " <br /> Auger I.D. y /y" <br /> SAMPLING - -- <br /> Holding Temperature sgdca'p <br /> Method <br /> Screening Method .. <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking sheet (y/n) OOMPLETION COMPLETION <br /> Ground Surface <br />� SPOILS <br /> grout <br /> Storage Method <br /> Contamination Noted - yes/no <br /> Storage Location n' <br /> i p <br /> O ' <br /> SPECIAL PERMIT INFO. <br /> stoned <br /> Distance to sewer line ' <br /> ss�Ion <br /> Domestic well on site - yes/no qn& P <br /> ark <br /> If yes, location & distance - — <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water [04.5 ' Casing type PAaQ PVC , <br /> Mix Ratios Blank WO, ft. Screen M�p � ft. <br /> Installation Method Slot size 0 . 0t0 <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br /> t <br />