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• OAGE_OF_L_ <br /> X <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: G " &'04,41,/ <br /> // ///�/��j/ CONSTRUCTION <br /> Premise Address: <br /> W'0 ,to Y '"" 17 Well No. <br /> Inspector: Total Depth <br /> Screen Length <br /> Filter Pack <br /> Bentonite Pellets <br /> Permit No. �`' ILI <br /> O'l Grout <br /> Consultant_ / Completion-Stove pi christie bo <br /> Geologist <br /> Auger O.D. <br /> Auger I <br /> SAMPLING <br /> atldtup <br /> Holding Temperature <br /> Method <br /> Screening Method ... <br /> ABOVEGROUND cHRISTY-BOX <br /> Tracking Sheet (y/n) 0010pLETpN cOMPLE110N <br /> Orourd Surface T--•� <br /> SPOILS grout <br /> Storage Method <br /> Contamination Noted - yes/no », <br /> Storage Location n, <br /> = m <br /> -- p <br /> _ m <br /> SPECIAL PERMIT INFO. __ u <br /> tbttad $ <br /> Distance to sewer line saCfion <br /> Domestic well on site - yes/no = praf pack <br /> If yes, location & distance - _ <br /> GROUTING `s <br /> MATERIALS USED! <br /> Depth to water Casing type <br /> Mix Ratios Blank ft. Screen ft. <br /> Installation Method Slot size <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> n Filter Pack type/size <br /> Total Billed Time Per Site <br /> �7�� �U <br /> Date Permit Finalized <br />