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AGF OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: Z- ' �� • CONSTRUCTION <br /> Premise Address: Well No. M4)'4- <br /> Inspector: Total Depth --(cD ' <br /> SC&ff�1 tl�l - ' <br /> Screen Length -&C)r --> -3$ <br /> Filter Pack -Coo, --., -so/ <br /> Bentonite Pellets <br /> Permit No. 41 - at3.9 Grout <br /> Consultant r Completion-Stove pipe/ ristie bo <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. 2 <br /> SAMPLING <br /> �� <br /> Holding Tem�,erstick-up <br /> lature _ <br /> Method / <br /> Screening Method <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (&n) COMPLETION COMPLETION <br /> Ground Surface <br /> SPOILS <br /> grout <br /> Storage Method -55 <br /> Contamination Noted - es/no ' <br /> Storage Location <br /> _ a <br /> — e <br /> SPECIAL PERMIT INFO. <br /> Distance to sewer line 71Sa I �secdon -' <br /> Domestic well on site - yes/® = grap <br /> ack <br /> If yes, location & distance - — <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type 554-40 A/C_ <br /> Mix Ratios ' Gkl /�-G!X Blanker ft. Screen 'L ft. <br /> Installation Method Slot size 0. 010 <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed 'Time Per Site <br /> Date Permit Finalized <br />