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%W %..0 PAGE / <br />MONITORING WELL INSTALLATION REPORT <br />Date: <br />Premise Address : Gzy S a `1•�0+"� <br />Inspector• <br />Permit No. d(P ° -7 <br />Consultant <br />Geologist <br />SAMPLING <br />Holding Temperature <br />Method <br />Screening Method <br />Tracking Sheet (y/n) <br />SPOILS <br />storage Method <br />Contamination Noted -Cyam/no <br />Storage Location <br />SPECIAL PERMIT INFO. Y <br />Distance to sewer line lJ <br />Domestic well on site - yes/ o <br />If yes, location & distance - <br />GROUTING <br />Depth to water 10 r <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />Total Billed'Time Per Site <br />Date Permit Finalized <br />Well No. Al <br />Total Depth <br />Screen Length 'ZI?f <br />Filter Pack IZ <br />Bentonite Pellets <br />Grout ! — Y <br />Completion -Stove pipestie box <br />Auger O.D. <br />Auger I.B. <br />_fi <br />MATERIALS USED: <br />Casing type_ <br />Blank ft. Screen ft. <br />Slot size <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />