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'PAGE <br /> • OF <br /> r <br /> NONITORING WELL INSTALLATION REPORT <br /> Date: <br /> CONSTRUCTION ` <br /> 1 Premise Address: 32U� . � ,' '�• r �, <br /> Inspector; <br /> Well No. <br /> QC-, Total Depth A. ' <br /> Screen Length - C, <br /> I . Filter Pack '/,2 b,.o•s ,r Sc ,� t� _� <br /> Permit No. G?U Bentonite Pellets <br /> Consultant s�-� �,ifrL Grout < <br /> Geologist Completion- tove pipe christie box <br /> Auger O.A. f r� <br /> l:- S LNG y Auger I.D. 4 � r <br />- Holding Temperature a>Jr*-up <br /> ,Method <br /> Screening Method------------- <br /> T <br /> Tracking Sheet (y/n? ABOVEGROUND T <br /> COMPLETION CHRISTY-BOX <br /> COMPLETION <br /> SPOILS Ormmd Surface <br /> Storage Method proof <br /> Contamination Noted - yes/no <br /> Storage Location n• <br /> SPECIAL PERMIT INFO. <br /> _ c <br /> Distance to sewer lineWoiwd r= <br /> Domestic well on site - yes/no 94wdon , <br /> If yes, location & distance - gra„a pack <br /> {' <br /> .i. <br /> GROUTING ....�.�n. R. . <br /> i• <br /> k <br /> MATERIALS USED. <br /> �S [ <br /> Depth to water <br /> Mix Ratios Casing t -Fg9d PI/C <br /> —�' 9 ype <br /> Installation Method Blank . ft. Screen, —ft. <br /> Quantity Installed —"-" Slot size +d`' <br /> Bags cement ; <br /> Buckets bentonite <br /> Bags sand/gravel <br /> 9 /gravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br /> )x <br /> f <br />