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PAGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Dates —[� U CONSTRUCTION <br /> oeo'I �r�� c ��] sk u/u G . ,t ,E � <br /> Premise %dd idi s: Well No. W <br /> Inspector: Total Depth <br /> ri rF Screen Length <br /> Filter Pack <br /> Bentonite Pellets--Lb- 13- <br /> Permit No. ` r fif�y Grout %3 +C3 S� r' c P <br /> Consultant_��QS�z �o _ Completion-Stove pipe/ hrist a box <br /> Geologist a/,I'S lr�e-'adt <br /> ts.laXAAe,* Keil,l Aucw . Auger O.D. !y <br /> Auger I.D. <br /> s✓B�� <br /> SAMPLING <br /> Holding Temperature slk*-up <br /> Method <br /> Screening Method ,. <br /> ABp1/8.GROUND CHRIM4OX <br /> Tracking Sheet (y/n) OOMPLETION COMPLETION <br /> Ground Sudace <br /> SPOILS <br /> grout <br /> Storage Method <br /> contamination Noted - yes/no ft' <br /> Storage Location <br /> 46 <br /> SPECIAL PERMIT INFO. :. n <br /> Distance to sewer line Mcdon <br /> Domestic well on site - yes/no <br /> If yes, location & distance - <br /> GROUTING r <br /> MATERIALS USED: <br /> Depth to water �� � Casing type P VC— Lie" _ <br /> Mix Ratios Blank Lft. Screen Z d ft. <br /> Installation Method Slot size . , 02 D <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Hags sand/gravel <br /> Filter Pack type/size <br /> Tota. Billed Time Per Site <br /> Date Permit finalized <br />