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' AGE ( OF l <br /> M . <br /> MONITORING WELL INSTALLATION REPORT <br /> Date : TC l l CONSTRUCTION <br /> Premise Address : t{ � - :./� <3 Well No . w -3 <br /> Inspectors / "wig Total Depth <br /> Screen Length <br /> Filter Pack .13V <br /> Bentonite Pellets 3 ' <br /> Permit No . Grout <br /> Consultant Completion-Stove, pip is ie box <br /> Geologist - U � '--� <br /> Auger O . D . <br /> Auger I . D . <br /> SAMPLING <br /> Holding Temperature stldaup <br /> Method <br /> Screening Method IV <br /> ABOVE-GROUND CHRISTY•BOX <br /> Tracking Sheet ( y / n ) COMPLETION COMPLETION <br /> �,�� Grourd Surlace —+SPOILS <br /> n grout <br /> Storage Method - arxA� <br /> „ <br /> Contamination Noted - _ye / no <br /> Storage Location <br /> —ta dw .fin. <br /> _ a <br /> = m <br /> SPECIAL PERMIT INFO . = c <br /> o <br /> slotted = c <br /> Distance to sewer line Becton <br /> Domestic well on site - yes / no <br /> If yes , location & distance - <br /> GROUTING <br /> MATERIALS USED : <br /> Depth to water 35 Casing type <br /> Mix Ratios7 • Blank 3�0 ft . Screen -2D ft . <br /> Installation MeiYAod Slot size <br /> Quantity Installed 50 Bags cement _ <br /> Buckets bentonite <br /> Bags sand/ gravel <br /> Filter Pack type / size alII <br /> ) <br /> Total Billed Time Per Site <br /> Date Permit Finalized / <br />