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PAGE OF�_ <br />MONITORING WELL INSTALLATION REPORT <br />Date: <br />Premise Address: <br />Inspector: <br />_. <br />Permit No. aj I- o(P177 <br />consultant <br />Geologist <br />SAMPLING <br />Holding Temperature <br />Method <br />E� <br />Screening Method <br />Tracking Sheet (y/n)_ <br />SPOILS <br />Storage Method 3�i�rzl <br />Contamination No ed -iuyes n <br />Storage Location <br />y 41 5'r. <br />SPECIAL PERMIT INFO. <br />J <br />Distance to sewer line - <br />Domestic <br />- <br />Domestic well on site yes <br />If yes, location & distance - <br />GROUTING <br />Depth to water + _' <br />Mix Ratios <br />Installation Method. <br />Quantity Installed ' <br />Total Billed'Time Per Site <br />Date Permit Finalized <br />Well No. <br />Total Depth <br />Screen Length_ <br />Filter Pack^ <br />Bentonite Pelletn <br />Grout <br />Completion -Stove pip christie box <br />Auger O.D. <br />Auger I.D. <br />ft. <br />MATERIALS USED: <br />Casing type � C - <br />k <br />Blanft. Screen 7-0 -ft. <br />L <br />slot size <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />w <br />