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f PAGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: 2-� ` �. C) <br /> CONSTRUCTION / <br /> Premise Address: F• ' <br /> i K.L." V� • l� Well No. 4"-W <br /> Inspector•�-� r � t ';n Total Depth <br /> Screen Length <br /> y , <br /> Filter <br /> Permit No. <br /> Bentonite Pellets 5 'S� <br /> 19� � � S3 i-( Grout <br /> Consultant ate.r <br /> Geologist CompletionStove pipe Christie box <br /> ► Auger D.D. ` <br /> Auger I.D. <br /> SAMPLING <br /> Bolding Temperature •tk*-up <br /> Method <br /> —Fill <br /> Screening Method �► : <br /> ABOVE-GACXJND C,KRIS 40X <br /> Tracking Sheet (y/n}, GOMPLkT10N <br /> COMPLUION <br /> SPOILS {kwnd Surfses <br /> III. yraut <br /> Storage Method <br /> Contamination Noted - yes/no ?t. <br /> Storage Location n• <br /> lid <br /> k SPECIAL PERMIT INFO. <br /> I n <br /> + Distance to sewer line &sth <br /> i tdon u`• -- <br /> Domestic well on site - yes/no <br /> If yes, location & distance - - 0MV01PS& <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water fo `R Casing ty e ��/ P,16 <br /> Mix Ratios Blank 1 0 ft. Screen 2,6 ft. <br /> Installation Method, Slot size <br /> Quantity Installed Hags cement <br /> Buckets bentonite <br /> r <br /> Bags sand/gravel. <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit,-Finalized <br />