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GAGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: ;2 - 14, 91 CONSTRUCTION / <br /> Premise Address: �3� s• CG'NT1312._ Well No. <br /> Inspector: Total Depth G n <br /> S. 5; ' tp b6vzScreen Length 0 <br /> Filter Pack ("o --�'- <br /> �+ Bentonite Pellets 3D <br /> Permit No. �� ` 0/ SIF Grout —2Zy' <br /> Consultant C Ir V _ Completion-Stove pipe�c ristie box <br /> Geologist FYI <br /> Auger O.D. g. 2 <br /> Auger I.D. <br /> SAMPLING _ --- -- <br /> Holding Temperature 4- atldc-up <br /> Method /!944 /CL--- <br /> Screening Method <br /> ABOVE-GROUND CHRISIY-BOX <br /> Tracking Sheet y/ ) COMPLE 1ON COMPLETION <br /> Ground Surface <br /> SPOILS <br /> grout <br /> Storage Method .55r, tyr <br /> Contamination Noted - �o n' <br /> Storage Location ft' <br /> ON Sc2— <br /> b <br /> SPECIAL PERMIT INFO. __ : <br /> Wottod __ c <br /> Distance to sewer line �5 sacdon _ <br /> Domestic well on site - yesllibrD — graveI P <br /> ack <br /> If yes, location & distance - — <br /> ft. <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water 7S Casing ty e .SC� ¢0 PVC_ 2 <br /> Mix Ratios �"�� Blanker ft. Screen ft. <br /> Installation Method IZ;— Slot size <br /> Quantity Installed Bags cement q SiAC41-5 <br /> Buckets bentonite / �941cc&f-"" <br /> Bags sand/gravel <br /> Filter Pack type/size 2 /2 <br /> Total Billed 'Time Per Site <br /> Date Permit Finalized <br />