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PAGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date. � T �Gi <br /> �,a� tt ' rr CONSTRUCTION <br /> Fremise�WLd esstA �uFnr.,t p16fi7 Well No. w <br /> Inspector: Total Depth 3Q- <br /> 7) <br /> 4� ���^G Screen Length .3e - r� <br /> Filter Pack 3 S - <br /> Bentonite Pellets <br /> Permit No. C� U-I TC90 Grout <br /> Consultant PS �, Completion-Stove pip t!E:7 box <br /> Geologist C411"%s rQ-f4w1r <br /> 4t/twf.�+t K�Jh l ,f}s.Srt Auger O.D. `r <br /> Auger I.D. <br /> SAMPLING -- <br /> Holding Temperature adck-up <br /> Method <br /> Screening Method T <br /> ABOVE-GROUND GHRiSIYBOx <br /> Tracking Sheet (y/n) CONPLUION <br /> GOMPl.ET10N <br /> Omound SWwo <br /> SPOILS <br /> of" <br /> Storage Method <br /> contamination Noted - yes/no ' <br /> Storage Location .�...�ti. dD <br /> n' <br /> -s <br /> SPECIAL PERMIT INFO. , . <br /> Waged <br /> Distance to sewer line Mtdon x' <br /> Domestic well on site - yea/no %. <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED• <br /> F� <br /> Depth to watercasing type IF,J <br /> Mix Ratios Blank LF r ft. Screen ?,-J ft. <br /> Installation Method Slot size •��U <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Balled Time Per Site <br /> Date Permit Finalized <br />